Provider Demographics
NPI:1912237991
Name:STORK, JEAN M (RD)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:M
Last Name:STORK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CENTER FOR CHILD HEALTH AND DEVELOPMENT
Mailing Address - Street 2:3901 RAINBOW BLVD., MSN 4003
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66160-0001
Mailing Address - Country:US
Mailing Address - Phone:913-945-6677
Mailing Address - Fax:913-588-8568
Practice Address - Street 1:CENTER FOR CHILD HEALTH AND DEVELOPMENT
Practice Address - Street 2:3901 RAINBOW BLVD., MSN 4003
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66160-0001
Practice Address - Country:US
Practice Address - Phone:913-945-6677
Practice Address - Fax:913-588-8568
Is Sole Proprietor?:No
Enumeration Date:2010-01-13
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1438133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200639390 AMedicaid