Healthcare Provider Details

I. General information

NPI: 1144435405
Provider Name (Legal Business Name): MISS BRENDA DARLENE JETTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18414 S HWY 75
MOUNDS OK
74047-7411
US

IV. Provider business mailing address

18414 S HWY 75
MOUNDS OK
74047-7411
US

V. Phone/Fax

Practice location:
  • Phone: 918-827-4022
  • Fax:
Mailing address:
  • Phone: 918-827-4022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number200063440A
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number20063440B
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number20063440C
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: