Provider Demographics
NPI:1154583862
Name:MALCOLM, JENNIFER KATHLEEN (DO)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:KATHLEEN
Last Name:MALCOLM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 SUNSET AVE
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66502-3739
Mailing Address - Country:US
Mailing Address - Phone:785-532-6544
Mailing Address - Fax:785-532-3425
Practice Address - Street 1:1105 SUNSET AVE
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66502-3739
Practice Address - Country:US
Practice Address - Phone:785-532-6544
Practice Address - Fax:785-532-3425
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02003812A207QS0010X
KS05-37550207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine