Healthcare Provider Details

I. General information

NPI: 1821463142
Provider Name (Legal Business Name): JACI MADDOX
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACI DILLON

II. Dates (important events)

Enumeration Date: 12/11/2015
Last Update Date: 02/21/2022
Certification Date: 02/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 S.W. PENN
BARTLESVILLE OK
74003-3847
US

IV. Provider business mailing address

700 S.W. PENN
BARTLESVILLE OK
74003-3847
US

V. Phone/Fax

Practice location:
  • Phone: 918-337-8080
  • Fax: 918-337-8099
Mailing address:
  • Phone: 918-337-8080
  • Fax: 918-337-8099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: