Healthcare Provider Details

I. General information

NPI: 1932578648
Provider Name (Legal Business Name): JEANA UNDERWOOD RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2015
Last Update Date: 09/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1511 W CHICKASAW AVE
SALLISAW OK
74955-7201
US

IV. Provider business mailing address

1511 W CHICKASAW AVE
SALLISAW OK
74955-7201
US

V. Phone/Fax

Practice location:
  • Phone: 918-926-7640
  • Fax: 918-926-7642
Mailing address:
  • Phone: 918-926-7640
  • Fax: 918-926-7642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number118086
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: