=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356332886
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEFF S. JENNINGS, DO, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2005
-----------------------------------------------------
Last Update Date | 07/29/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 W CHEROKEE ST
-----------------------------------------------------
City | WAGONER
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74467-4624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-485-5514
-----------------------------------------------------
Fax | 918-485-9701
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4500 S GARNETT RD 300
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74146-5229
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-664-9892
-----------------------------------------------------
Fax | 918-664-2521
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JEFF S JENNINGS
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 918-687-6335
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------