Provider Demographics
NPI:1760454730
Name:SMITH, JILL MARIE (OD)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4181 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64111-2620
Mailing Address - Country:US
Mailing Address - Phone:816-756-3577
Mailing Address - Fax:816-756-3069
Practice Address - Street 1:4181 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-2620
Practice Address - Country:US
Practice Address - Phone:816-756-3577
Practice Address - Fax:816-756-3069
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-03
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT03249152W00000X
KS1468152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100220990DMedicaid
MO318585205Medicaid
MO318585205Medicaid