Provider Demographics
NPI:1932627502
Name:COLE, SARA JANE (PSYD)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:JANE
Last Name:COLE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 721
Mailing Address - Street 2:
Mailing Address - City:BLUE SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64013-0721
Mailing Address - Country:US
Mailing Address - Phone:816-598-4336
Mailing Address - Fax:
Practice Address - Street 1:1924 NW COPPER OAKS CIR
Practice Address - Street 2:
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64015-8300
Practice Address - Country:US
Practice Address - Phone:816-598-4336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-05
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017021453103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490053259Medicaid
KS20120900AMedicaid