Healthcare Provider Details

I. General information

NPI: 1265525042
Provider Name (Legal Business Name): JEANNIE M MCCANCE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 10/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

826 E BROADWAY
MUSKOGEE OK
74403
US

IV. Provider business mailing address

826 E BROADWAY
MUSKOGEE OK
74403
US

V. Phone/Fax

Practice location:
  • Phone: 918-687-1634
  • Fax: 918-398-4408
Mailing address:
  • Phone: 918-687-1634
  • Fax: 918-398-4408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number16881
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: