Basic Information
| Provider Information | |||||||||
| NPI: | 1205967866 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHERIDAN | ||||||||
| FirstName: | JILL | ||||||||
| MiddleName: | RENE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | OTR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21314 W 48TH ST | ||||||||
| Address2: | |||||||||
| City: | SHAWNEE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662189448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9134415324 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10300 W 103RD ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662142642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9138941910 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 17-01587 | KS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 17-01587 | 01 | KS | STATE LICENSE | OTHER |