Provider Demographics
NPI:1972781847
Name:GRAUE, JACKIE ANN BURR (NP)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:ANN BURR
Last Name:GRAUE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:ANN
Other - Last Name:BURR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:3415 MC INTOSH CIR
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-3651
Mailing Address - Country:US
Mailing Address - Phone:417-347-1111
Mailing Address - Fax:417-347-4064
Practice Address - Street 1:3415 MC INTOSH CIR
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-3651
Practice Address - Country:US
Practice Address - Phone:417-347-1111
Practice Address - Fax:417-347-4064
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-04
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO110313363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily