Provider Demographics
NPI:1013499656
Name:WASSON, JILLIAN WOODFORD
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:WOODFORD
Last Name:WASSON
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 1:14237 W 113TH TER
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66215-4825
Mailing Address - Country:US
Mailing Address - Phone:908-246-1975
Mailing Address - Fax:
Practice Address - Street 1:8700 INDIAN CREEK PKWY STE 270
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66210-1527
Practice Address - Country:US
Practice Address - Phone:908-246-1975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-30
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X, 103TC1900X
KST-LP2621103T00000X
KS2701103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling