Provider Demographics
NPI:1336740620
Name:JACK, COURTNEY J (APRN-BC)
Entity type:Individual
Prefix:MS
First Name:COURTNEY
Middle Name:J
Last Name:JACK
Suffix:
Gender:
Credentials:APRN-BC
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:J
Other - Last Name:PERKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN-BC
Mailing Address - Street 1:724 SW 30TH ST
Mailing Address - Street 2:
Mailing Address - City:BLUE SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64015-3381
Mailing Address - Country:US
Mailing Address - Phone:816-718-7484
Mailing Address - Fax:
Practice Address - Street 1:400 SW LONGVIEW BLVD STE 280
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64081-2157
Practice Address - Country:US
Practice Address - Phone:816-477-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-04
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.031610363LF0000X
MO2020029102363LF0000X
KS79693363LF0000X
IAA181796363LF0000X
OH0038214363LF0000X
WI16215-33363LF0000X
IN71016015A363LF0000X
MN12487363LF0000X
NE115898363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily