Healthcare Provider Details

I. General information

NPI: 1992428098
Provider Name (Legal Business Name): JESSICA MCCLELLAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2022
Last Update Date: 09/22/2022
Certification Date: 09/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1728 S CARSON AVE
TULSA OK
74119-4610
US

IV. Provider business mailing address

13774 W 834 RD
TAHLEQUAH OK
74464-1511
US

V. Phone/Fax

Practice location:
  • Phone: 918-406-3420
  • Fax:
Mailing address:
  • Phone: 918-837-1813
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: