Healthcare Provider Details

I. General information

NPI: 1912586462
Provider Name (Legal Business Name): JENNIFER CHEYANNE WILKIE DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2021
Last Update Date: 02/07/2025
Certification Date: 02/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19600 E ROSS ST
TAHLEQUAH OK
74464-0545
US

IV. Provider business mailing address

19600 E ROSS ST
TAHLEQUAH OK
74464-0545
US

V. Phone/Fax

Practice location:
  • Phone: 539-234-4100
  • Fax: 539-234-4453
Mailing address:
  • Phone: 539-234-4100
  • Fax: 539-234-4453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number7731
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: