Healthcare Provider Details

I. General information

NPI: 1871259879
Provider Name (Legal Business Name): JT HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2021
Last Update Date: 05/10/2023
Certification Date: 05/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 E. GRAND
TONKAWA OK
74653-3503
US

IV. Provider business mailing address

1605 COUNTRY RD
BLACKWELL OK
74631-6749
US

V. Phone/Fax

Practice location:
  • Phone: 580-789-1628
  • Fax: 888-712-9476
Mailing address:
  • Phone: 580-716-0245
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TAMMIE D REGGIO
Title or Position: PRIMARY PROVIDER
Credential: PA
Phone: 580-789-1628