Healthcare Provider Details

I. General information

NPI: 1811760424
Provider Name (Legal Business Name): JESSICA MARSHALL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2023
Last Update Date: 11/06/2023
Certification Date: 11/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 CHILDRENS AVE
OKLAHOMA CITY OK
73104-4637
US

IV. Provider business mailing address

718 E COTTONWOOD LN
ENID OK
73701-6927
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-4876
  • Fax:
Mailing address:
  • Phone: 580-548-6993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License Number5151
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: