Healthcare Provider Details

I. General information

NPI: 1912974007
Provider Name (Legal Business Name): MRS. JENNIFER CALDWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 11/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7641 MERCURY RD
TINKER AFB OK
73145-8707
US

IV. Provider business mailing address

10504 WILLOW RIDGE DR
MIDWEST CITY OK
73130-6034
US

V. Phone/Fax

Practice location:
  • Phone: 405-739-3990
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier1710I1002X
Identifier TypeOTHER
Identifier StateOK
Identifier IssuerINDEPENDENT DUTY CORPSMAN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: