Healthcare Provider Details

I. General information

NPI: 1336981992
Provider Name (Legal Business Name): JEREMY FOSTER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2024
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 W 4TH ST
ADA OK
74820-3411
US

IV. Provider business mailing address

PO BOX 189
ARDMORE OK
73402-0189
US

V. Phone/Fax

Practice location:
  • Phone: 580-436-2690
  • Fax: 580-436-2695
Mailing address:
  • Phone: 580-319-7305
  • Fax: 580-319-7328

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: