Basic Information
| Provider Information | |||||||||
| NPI: | 1801202882 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JEFFRESS | ||||||||
| FirstName: | ERIN | ||||||||
| MiddleName: | KELLIE | ||||||||
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| Credential: | COTA/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 731 N KLEIN CIR | ||||||||
| Address2: | |||||||||
| City: | DERBY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 670377011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3164409617 | ||||||||
| FaxNumber: | 3164409619 | ||||||||
| Practice Location | |||||||||
| Address1: | 3500 N ROCK RD, BUILDING 2200, STE 101 | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 67226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3164403316 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2014 | ||||||||
| LastUpdateDate: | 01/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 18-00781 | KS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 18-00781 | 01 | KS | KANSAS BOARD OF HEALING ARTS | OTHER |