Healthcare Provider Details

I. General information

NPI: 1083154009
Provider Name (Legal Business Name): JILL SWANSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2017
Last Update Date: 02/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1034 S BRENTWOOD BLVD STE 300
RICHMOND HEIGHTS MO
63117-1203
US

IV. Provider business mailing address

1034 S BRENTWOOD BLVD STE 300
RICHMOND HEIGHTS MO
63117-1203
US

V. Phone/Fax

Practice location:
  • Phone: 314-644-5730
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2016025073
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056.011739
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: