Provider Demographics
NPI:1114277803
Name:BADER, JENNIFER LEANN (FNP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEANN
Last Name:BADER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LEANN
Other - Last Name:LAWRENCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:6738 STATE HIGHWAY 77
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63736-8238
Mailing Address - Country:US
Mailing Address - Phone:573-313-2500
Mailing Address - Fax:573-313-2505
Practice Address - Street 1:920 KENNETT ST
Practice Address - Street 2:
Practice Address - City:KENNETT
Practice Address - State:MO
Practice Address - Zip Code:63857-3817
Practice Address - Country:US
Practice Address - Phone:573-717-1130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-11
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005022001363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily