Provider Demographics
NPI:1083920029
Name:TRYON, JACKIE KIM (RN)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:KIM
Last Name:TRYON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9405 N OAK TRFY
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64155-2233
Mailing Address - Country:US
Mailing Address - Phone:816-412-2900
Mailing Address - Fax:816-412-2915
Practice Address - Street 1:9405 N OAK TRFY
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64155-2233
Practice Address - Country:US
Practice Address - Phone:816-412-2900
Practice Address - Fax:816-412-2915
Is Sole Proprietor?:No
Enumeration Date:2010-08-27
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO082544163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant