Provider Demographics
NPI:1770528283
Name:OTHMER, JENNIFER L (CNS)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:OTHMER
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:MATUKAITIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 931168
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64193-0001
Mailing Address - Country:US
Mailing Address - Phone:816-461-8288
Mailing Address - Fax:816-461-6586
Practice Address - Street 1:4401 WORNALL RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-3220
Practice Address - Country:US
Practice Address - Phone:816-932-2179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005027490364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00281701Medicare PIN
MOF06E374BMedicare PIN
MOQ62682Medicare UPIN