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
StateLicense IDTaxonomies
MO2004021723103TB0200X, 103TC0700X, 103TH0100X
KSLP03007103TB0200X, 103TH0100X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service