Healthcare Provider Details

I. General information

NPI: 1780359836
Provider Name (Legal Business Name): JACY RHAE REITER DNP-APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2021
Last Update Date: 08/11/2021
Certification Date: 08/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6001 NW 139TH ST STE A
OKLAHOMA CITY OK
73142-1919
US

IV. Provider business mailing address

6001 NW 139TH ST STE A
OKLAHOMA CITY OK
73142-1919
US

V. Phone/Fax

Practice location:
  • Phone: 405-635-3511
  • Fax: 405-603-2240
Mailing address:
  • Phone: 405-635-3511
  • Fax: 405-603-2240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number204976
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number204976
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: