Provider Demographics
NPI: | 1467669960 |
---|---|
Name: | VANDER WAL, JILLON S |
Entity Type: | Individual |
Prefix: | DR |
First Name: | JILLON |
Middle Name: | S |
Last Name: | VANDER WAL |
Suffix: | |
Gender: | F |
Credentials: | |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 14934 S TURNBERRY ST |
Mailing Address - Street 2: | |
Mailing Address - City: | OLATHE |
Mailing Address - State: | KS |
Mailing Address - Zip Code: | 66061-6033 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 314-255-6703 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 4801 E LINWOOD BLVD |
Practice Address - Street 2: | |
Practice Address - City: | KANSAS CITY |
Practice Address - State: | MO |
Practice Address - Zip Code: | 64128-2226 |
Practice Address - Country: | US |
Practice Address - Phone: | 816-861-4700 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2007-05-16 |
Last Update Date: | 2022-05-31 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MO | 2004021723 | 103TB0200X, 103TC0700X, 103TH0100X |
KS | LP03007 | 103TB0200X, 103TH0100X, 103TC0700X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 103TC0700X | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No | 103TB0200X | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral |
No | 103TH0100X | Behavioral Health & Social Service Providers | Psychologist | Health Service |