Healthcare Provider Details

I. General information

NPI: 1285809632
Provider Name (Legal Business Name): JENNIFER L HANSLICK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2008
Last Update Date: 02/26/2020
Certification Date: 02/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 S UTICA AVE SUITE 2123
TULSA OK
74104-4012
US

IV. Provider business mailing address

1120 S UTICA AVE SUITE 2123
TULSA OK
74104
US

V. Phone/Fax

Practice location:
  • Phone: 918-579-5402
  • Fax: 918-579-5404
Mailing address:
  • Phone: 918-579-5402
  • Fax: 918-579-5404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2009012792
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberMD177451
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number2009012792
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number32635
License Number StateOK
# 5
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number49529
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: