Healthcare Provider Details

I. General information

NPI: 1720711252
Provider Name (Legal Business Name): JESSICA NICOLE CANTRELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2022
Last Update Date: 09/11/2025
Certification Date: 07/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7146 WALTON LN
MCLOUD OK
74851-8185
US

IV. Provider business mailing address

7146 WALTON LN
MCLOUD OK
74851-8185
US

V. Phone/Fax

Practice location:
  • Phone: 405-432-7658
  • Fax:
Mailing address:
  • Phone: 405-432-7658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: