Provider Demographics
NPI:1164942694
Name:CROCKER, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:CROCKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16401 POPLAR AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64136-1287
Mailing Address - Country:US
Mailing Address - Phone:816-519-0326
Mailing Address - Fax:
Practice Address - Street 1:4200 REGENT ST STE 200
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43219-6229
Practice Address - Country:US
Practice Address - Phone:877-870-1775
Practice Address - Fax:614-968-8840
Is Sole Proprietor?:No
Enumeration Date:2017-06-26
Last Update Date:2025-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017021767363LF0000X
MO2015040563363LF0000X
KS14-123272-031363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily