Healthcare Provider Details

I. General information

NPI: 1710530688
Provider Name (Legal Business Name): JESSICA KLINGEMAN APRN-CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2019
Last Update Date: 04/14/2023
Certification Date: 04/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17675 S MUSKOGEE AVE
TAHLEQUAH OK
74464-5492
US

IV. Provider business mailing address

PO BOX 948
TAHLEQUAH OK
74465-0948
US

V. Phone/Fax

Practice location:
  • Phone: 918-453-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number124281
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: