Basic Information
| Provider Information | |||||||||
| NPI: | 1205887502 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JESTER | ||||||||
| FirstName: | TERI | ||||||||
| MiddleName: | DENE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NEW | ||||||||
| OtherFirstName: | TERI | ||||||||
| OtherMiddleName: | DENE | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 3727 | ||||||||
| Address2: | |||||||||
| City: | LAWRENCE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660460727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8779060924 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3511 CLINTON PL | ||||||||
| Address2: | |||||||||
| City: | LAWRENCE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660472196 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7853313783 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 1700838 | KS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 117007 | 01 | KS | BCBS OF KS | OTHER | 26031032 | 01 | KS | BCBS KC | OTHER |