Basic Information
| Provider Information | |||||||||
| NPI: | 1578679379 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JEFFERS-GRAY | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | SUE | ||||||||
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| Credential: | MOT, OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 850 43RD AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | MOLINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612658401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097432070 | ||||||||
| FaxNumber: | 3097432073 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 OVESEN DR | ||||||||
| Address2: | |||||||||
| City: | WILTON | ||||||||
| State: | IA | ||||||||
| PostalCode: | 527789612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5637324317 | ||||||||
| FaxNumber: | 5637324318 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2006 | ||||||||
| LastUpdateDate: | 03/29/2018 | ||||||||
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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 | 225XP0200X | 01527 | IA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics | 225X00000X | 01527 | IA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0665711 | 05 | IA | MEDICAID | 38037 | 01 | IA | BLUE CROSS BLUE SHIELD | OTHER | I15598 | 01 | IA | MEDICARE | OTHER |