Provider Demographics
NPI:1700266582
Name:JAMISON, THERESA RENE (PD)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:RENE
Last Name:JAMISON
Suffix:
Gender:F
Credentials:PD
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:RENE
Other - Last Name:FORST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3901 RAINBOW BLVD
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66160-8500
Mailing Address - Country:US
Mailing Address - Phone:913-588-5590
Mailing Address - Fax:913-588-5916
Practice Address - Street 1:3901 RAINBOW BLVD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66160-8500
Practice Address - Country:US
Practice Address - Phone:913-588-5590
Practice Address - Fax:913-588-5916
Is Sole Proprietor?:No
Enumeration Date:2015-06-05
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLP 2309103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool