Healthcare Provider Details

I. General information

NPI: 1093087355
Provider Name (Legal Business Name): JENNIFER SOUTHARD MS, RD/LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2012
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3120 S BOULEVARD STE 127
EDMOND OK
73013-5308
US

IV. Provider business mailing address

10600 S PENNSYLVANIA AVE STE 16
OKLAHOMA CITY OK
73170-4257
US

V. Phone/Fax

Practice location:
  • Phone: 405-960-3120
  • Fax:
Mailing address:
  • Phone: 405-960-3120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1720
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: