Provider Demographics
NPI:1871338590
Name:O'MALLEY, JERRAD
Entity type:Individual
Prefix:
First Name:JERRAD
Middle Name:
Last Name:O'MALLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22120 MIDLAND DR
Mailing Address - Street 2:STE 1
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66112-3574
Mailing Address - Country:US
Mailing Address - Phone:913-745-4064
Mailing Address - Fax:913-745-4352
Practice Address - Street 1:2113 E KANSAS CITY RD
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66061-7050
Practice Address - Country:US
Practice Address - Phone:913-791-0144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-25
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-07625225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty