Healthcare Provider Details

I. General information

NPI: 1144239229
Provider Name (Legal Business Name): JENNIFER L BERENDS DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2006
Last Update Date: 01/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 S MAIN
SHATTUCK OK
73858-0703
US

IV. Provider business mailing address

PO BOX 703
SHATTUCK OK
73858-0703
US

V. Phone/Fax

Practice location:
  • Phone: 580-938-5275
  • Fax: 580-938-2256
Mailing address:
  • Phone: 580-938-5275
  • Fax: 580-938-2256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4504
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: