=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215827795
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER ANN DILLARD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2025
-----------------------------------------------------
Last Update Date | 07/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 513 AVALON
-----------------------------------------------------
City | VIAN
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74962-1040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 185-399-7709
-----------------------------------------------------
Fax | 918-871-5039
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 513 AVALON
-----------------------------------------------------
City | VIAN
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74962-1040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 185-399-7709
-----------------------------------------------------
Fax | 918-871-5039
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 175T00000X
-----------------------------------------------------
Taxonomy Name | Peer Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------