Provider Demographics
NPI:1174959365
Name:UTTERBACK, JENNIFER (APRN-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:UTTERBACK
Suffix:
Gender:F
Credentials:APRN-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 NW R D MIZE RD
Mailing Address - Street 2:EMERGENCY DEPARTMENT
Mailing Address - City:BLUE SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64014-2513
Mailing Address - Country:US
Mailing Address - Phone:816-655-5472
Mailing Address - Fax:
Practice Address - Street 1:20 NW R.D. MIZE ROAD
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64014-4411
Practice Address - Country:US
Practice Address - Phone:816-655-5472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-19
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM65688363LF0000X
KS53-79796-122363LF0000X
MO2013032468363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1174959365Medicaid
MO1174959365Medicaid
P01354811Medicare PIN