Healthcare Provider Details

I. General information

NPI: 1417174632
Provider Name (Legal Business Name): JENNIFER PHILLIPS R.N.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 KAUFMAN AVE
TAHLEQUAH OK
74464-5145
US

IV. Provider business mailing address

802 KAUFMAN AVE
TAHLEQUAH OK
74464-5145
US

V. Phone/Fax

Practice location:
  • Phone: 918-456-9524
  • Fax:
Mailing address:
  • Phone: 918-456-9524
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberR0028259
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: