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Individual provider Active NPI

Jackie Jean Sutherland, DO

  • Internal Medicine Physician
  • Kennett, MO
National Provider Identifier
1720088347
Registry record updated Sep 5, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
License
2003013951 Issued in MO
Practice address
603 Teaco Road
Kennett, MO 63857-3266
Phone
(573) 717-7676
Fax
(573) 717-7877
NPI assigned
Jul 26, 2005
Sex
Female
Sole proprietor
Yes

NPPES NPI Registry

Updated by the provider on Sep 5, 2012

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine Physician 207R00000X 2003013951 MO Primary

Addresses

Primary practice location

603 Teaco Road
Kennett, MO 63857-3266

Mailing address

603 Teaco Road.
Kennett, MO 63857-3266
Phone (573) 717-7676

Other identifiers 2

IdentifierTypeStateIssuer
209180900MedicaidMO
192785OtherMOBCBS

Other names 1

  • Mrs. Jackie Jean Turner Former name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MO
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20040917000098 MO Practitioner - Internal Medicine 4082682117 Practice locations: Kennett, MO

Care Compare profile

Medicare Care Compare
Specialty
Internal Medicine
Education
Other, 2001
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Health Facilities Rehab Services IncGroup PAC ID 3476679226, 152 clinicians
McPherson Medical and Diagnostic LLCGroup PAC ID 5698773539, shared by 11 NPIs, 88 clinicians

Practice addresses (Care Compare)

1102 Sikes Ave
Sikeston, MO 63801-5021

216 W Main St
Steele, MO 63877-1436
Phone (573) 695-2181

Hospital & facility affiliations

Merit-based Incentive Payment System (MIPS)

Final score
100 of 100Reported as individual
Quality
100
Improvement activities
40
Cost
79.91

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Osteopathy

State licenses

LicenseStateTypeSpecialty
2003013951MOMDInternal Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
NHC Healthcare-Kennett LLC Past Accepting new patients
Ozarks Medical Center Past Accepting new patients

Ownership & related parties

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
NHC Healthcare KennettKennett, MO, CCN 265168 Skilled nursing facility Operational/Managerial Control
Adp of the SNF		 Jan 5, 2007
Jan 5, 2007

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Organizations & group practices 3

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 10

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1122336000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1346803200000",
    "number": "1720088347",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "603 TEACO ROAD.",
            "city": "KENNETT",
            "state": "MO",
            "postal_code": "638573266",
            "telephone_number": "573-717-7676",
            "fax_number": "573-717-7877"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "603 TEACO ROAD",
            "city": "KENNETT",
            "state": "MO",
            "postal_code": "638573266",
            "telephone_number": "573-717-7676",
            "fax_number": "573-717-7877"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "SUTHERLAND",
        "first_name": "JACKIE",
        "middle_name": "JEAN",
        "name_prefix": "Mrs.",
        "credential": "DO",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2005-07-26",
        "last_updated": "2012-09-05",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "MO",
            "license": "2003013951",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "209180900",
            "state": "MO"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "192785",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "JACKIE",
            "last_name": "TURNER",
            "middle_name": "JEAN",
            "prefix": "MRS.",
            "credential": "DO",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

Other providers in Kennett, MO

Sources for this page

Verify at the official NPI Registry.