Healthcare Provider Details

I. General information

NPI: 1184227514
Provider Name (Legal Business Name): JO LYN HARDAGE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2020
Last Update Date: 07/26/2021
Certification Date: 07/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 E 5TH PL
TULSA OK
74104-2905
US

IV. Provider business mailing address

5310 E 31ST ST
TULSA OK
74135-5018
US

V. Phone/Fax

Practice location:
  • Phone: 918-833-9900
  • Fax:
Mailing address:
  • Phone: 918-600-3100
  • Fax: 918-560-1399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: