Provider Demographics
NPI:1841303807
Name:BRULL, JENNIFER L (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:BRULL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 N WASHINGTON
Mailing Address - Street 2:
Mailing Address - City:PLAINVILLE
Mailing Address - State:KS
Mailing Address - Zip Code:67663-1632
Mailing Address - Country:US
Mailing Address - Phone:785-434-2622
Mailing Address - Fax:785-434-2577
Practice Address - Street 1:1210 N WASHINGTON
Practice Address - Street 2:
Practice Address - City:PLAINVILLE
Practice Address - State:KS
Practice Address - Zip Code:67663-1632
Practice Address - Country:US
Practice Address - Phone:785-434-2622
Practice Address - Fax:785-434-2577
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-28262207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100376880CMedicaid
KS110760Medicare ID - Type UnspecifiedMEDICARE GROUP
KS101898Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL
KS100376880CMedicaid