Provider Demographics
NPI:1649434200
Name:KING, JESSICA RENEE (MD)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:RENEE
Last Name:KING
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JESSICA
Other - Middle Name:RENEE
Other - Last Name:VAN BIBBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1905 W 19TH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN GROVE
Mailing Address - State:MO
Mailing Address - Zip Code:65711-1287
Mailing Address - Country:US
Mailing Address - Phone:417-926-1770
Mailing Address - Fax:417-926-1785
Practice Address - Street 1:1905 W 19TH ST
Practice Address - Street 2:
Practice Address - City:MOUNTAIN GROVE
Practice Address - State:MO
Practice Address - Zip Code:65711-1287
Practice Address - Country:US
Practice Address - Phone:417-926-1770
Practice Address - Fax:417-926-1785
Is Sole Proprietor?:No
Enumeration Date:2008-07-14
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008017836207Q00000X
MO2009020461207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO26D2006074OtherCLIA
MO504114802Medicaid
MO26D0889777OtherCLIA
MO1649434200Medicaid
MO594438806Medicaid
MO507780302Medicaid
MO204253207Medicaid
MO597780303Medicaid
MOP01296849OtherRAILROAD MEDICARE