Healthcare Provider Details

I. General information

NPI: 1134865272
Provider Name (Legal Business Name): JILLIAN COOPER RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2022
Last Update Date: 05/11/2022
Certification Date: 04/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 S LEE ST STE A
FORT GIBSON OK
74434-8710
US

IV. Provider business mailing address

113 NORH 6 MILE LANE
FORT GIBSON OK
74434
US

V. Phone/Fax

Practice location:
  • Phone: 918-478-4433
  • Fax:
Mailing address:
  • Phone: 918-869-0089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number3257
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: