Healthcare Provider Details

I. General information

NPI: 1710402946
Provider Name (Legal Business Name): JENNIFER LYNN CHEATHAM MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2017
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1605 N HARRISON ST
SHAWNEE OK
74804-4022
US

IV. Provider business mailing address

1605 N HARRISON ST
SHAWNEE OK
74804-4022
US

V. Phone/Fax

Practice location:
  • Phone: 405-395-2602
  • Fax:
Mailing address:
  • Phone: 405-395-2602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC07199
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: