Healthcare Provider Details

I. General information

NPI: 1740694611
Provider Name (Legal Business Name): JENNA LYNN CROWDER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2014
Last Update Date: 09/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1616 S KELLY AVE
EDMOND OK
73013-3651
US

IV. Provider business mailing address

1616 S KELLY AVE
EDMOND OK
73013-3651
US

V. Phone/Fax

Practice location:
  • Phone: 405-348-8838
  • Fax: 405-348-8837
Mailing address:
  • Phone: 405-348-8838
  • Fax: 405-348-8837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number34063
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: