Provider Demographics
NPI:1568555175
Name:SHRIVER, JILL S (RD)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:S
Last Name:SHRIVER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. POX 1266
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:KS
Mailing Address - Zip Code:66762
Mailing Address - Country:US
Mailing Address - Phone:620-232-0133
Mailing Address - Fax:620-232-0163
Practice Address - Street 1:1 MT. CARMEL WAY
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:KS
Practice Address - Zip Code:66762
Practice Address - Country:US
Practice Address - Phone:620-232-0133
Practice Address - Fax:620-232-0163
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1139133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS130448Medicare ID - Type Unspecified
P49498Medicare UPIN