Provider Demographics
NPI:1215753397
Name:DAVIDSON, JILL
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:DAVIDSON
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 1:12322 PAWNEE LN
Mailing Address - Street 2:
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66209-1407
Mailing Address - Country:US
Mailing Address - Phone:660-346-0343
Mailing Address - Fax:
Practice Address - Street 1:10205 STATE LINE RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64114-4263
Practice Address - Country:US
Practice Address - Phone:816-354-3090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-23
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSTMP-162518363LF0000X
MO2024047258363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily