Healthcare Provider Details

I. General information

NPI: 1124909122
Provider Name (Legal Business Name): JAMIE PEMBERTON PRSS, CM 1
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2025
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6100 S. WALKER AVE.
OKLAHOMA CITY OK
73139
US

IV. Provider business mailing address

6100 S WALKER AVE
OKLAHOMA CITY OK
73139-7026
US

V. Phone/Fax

Practice location:
  • Phone: 405-634-4400
  • Fax:
Mailing address:
  • Phone: 405-634-4400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number1124909122
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: