Healthcare Provider Details

I. General information

NPI: 1255726212
Provider Name (Legal Business Name): MS. JILL SHANTEAU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JILL DEROWITSCH

II. Dates (important events)

Enumeration Date: 04/06/2015
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 DEERFOOT WAY
COLUMBIA MO
65203-6758
US

IV. Provider business mailing address

3900 DEERFOOT WAY
COLUMBIA MO
65203-6758
US

V. Phone/Fax

Practice location:
  • Phone: 571-217-6906
  • Fax:
Mailing address:
  • Phone: 571-217-6906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2017030508
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number0903001575
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: