Provider Demographics
NPI:1740541234
Name:HUMBLE, JESSILYN RANAE (MD)
Entity type:Individual
Prefix:DR
First Name:JESSILYN
Middle Name:RANAE
Last Name:HUMBLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2711 S ROUSE ST STE B
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:KS
Mailing Address - Zip Code:66762-6621
Mailing Address - Country:US
Mailing Address - Phone:620-235-7612
Mailing Address - Fax:620-235-7613
Practice Address - Street 1:2711 S ROUSE ST STE B
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:KS
Practice Address - Zip Code:66762-6621
Practice Address - Country:US
Practice Address - Phone:620-235-7612
Practice Address - Fax:620-235-7613
Is Sole Proprietor?:No
Enumeration Date:2012-05-31
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-38113208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201118970AMedicaid