=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811702426
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA DORIS TIPTON APRN-CNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2025
-----------------------------------------------------
Last Update Date | 12/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12656 LOVES VALLEY RD
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73448-7001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-238-8536
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12656 LOVES VALLEY RD
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73448-7001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-238-8536
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 222016
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------