Provider Demographics
NPI:1740258367
Name:SCHENKELBERG, JACKIE M (DO)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:M
Last Name:SCHENKELBERG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:M
Other - Last Name:FOX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:4801 E LINWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64128-2226
Mailing Address - Country:US
Mailing Address - Phone:816-861-4700
Mailing Address - Fax:
Practice Address - Street 1:4801 E LINWOOD BLVD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64128-2226
Practice Address - Country:US
Practice Address - Phone:816-861-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006005516207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200468007Medicaid
KS200271340 CMedicaid
MOP00318282OtherRR MEDICARE
MOP00318282OtherRR MEDICARE
I19349Medicare UPIN