Healthcare Provider Details

I. General information

NPI: 1669731568
Provider Name (Legal Business Name): JERRI L BOATNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2012
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16820 STATE HIGHWAY 9 E
EUFAULA OK
74432-5220
US

IV. Provider business mailing address

615 W WASHINGTON ST
TECUMSEH OK
74873-2832
US

V. Phone/Fax

Practice location:
  • Phone: 918-452-3335
  • Fax: 918-452-3939
Mailing address:
  • Phone: 405-432-3115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number9212
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: