Healthcare Provider Details

I. General information

NPI: 1811607690
Provider Name (Legal Business Name): J K AT HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2022
Last Update Date: 04/06/2023
Certification Date: 04/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2237 W MEMORIAL RD STE 112
OKLAHOMA CITY OK
73134-8064
US

IV. Provider business mailing address

2237 W MEMORIAL RD STE 112
OKLAHOMA CITY OK
73134-8064
US

V. Phone/Fax

Practice location:
  • Phone: 405-808-3714
  • Fax:
Mailing address:
  • Phone: 405-808-3714
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: JILLIAN HERNDON
Title or Position: OWNER
Credential:
Phone: 405-808-3714