Provider Demographics
NPI:1801202882
Name:JEFFRESS, ERIN KELLIE (COTA/L)
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:KELLIE
Last Name:JEFFRESS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:731 N KLEIN CIR
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:KS
Mailing Address - Zip Code:67037-7011
Mailing Address - Country:US
Mailing Address - Phone:316-440-9617
Mailing Address - Fax:316-440-9619
Practice Address - Street 1:3500 N ROCK RD, BUILDING 2200, STE 101
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226
Practice Address - Country:US
Practice Address - Phone:316-440-3316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-10
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS18-00781224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS18-00781OtherKANSAS BOARD OF HEALING ARTS