Healthcare Provider Details

I. General information

NPI: 1710261433
Provider Name (Legal Business Name): JENNY LEIGH CLEMENS CNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2011
Last Update Date: 09/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 MONROE ST
PAULS VALLEY OK
73075-5034
US

IV. Provider business mailing address

106 MONROE ST
PAULS VALLEY OK
73075-5034
US

V. Phone/Fax

Practice location:
  • Phone: 405-207-0941
  • Fax:
Mailing address:
  • Phone: 405-207-0941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number37T012270408
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: