Healthcare Provider Details

I. General information

NPI: 1225136724
Provider Name (Legal Business Name): JENNIE LEIRD PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 N PORTLAND AVE
OKLAHOMA CITY OK
73116-2035
US

IV. Provider business mailing address

1001 NW 9TH ST
MOORE OK
73160-1811
US

V. Phone/Fax

Practice location:
  • Phone: 405-879-9947
  • Fax:
Mailing address:
  • Phone: 405-317-3317
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number1414
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: