MEDICARE: JODI JENISTA APRN-CNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	89504	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	89504	OTHER	OK	STATE LICENSE

General Provider Information

NPI Number	:	1104205186
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JODI JENISTA APRN-CNP

Provider Business Mailing Address
First Line	:	6 EARLY DAWN DR
Second Line	:
City	:	EDMOND
State	:	OK
Zip	:	73034-7018
Country	:	US
Telephone Number	:	405-255-9146
Fax Number	:

Provider Business Practice Location Address
First Line	:	2925 ASTORIA WAY
Second Line	:
City	:	EDMOND
State	:	OK
Zip	:	73034-5997
Country	:	US
Telephone Number	:	405-254-3000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2015
Last Update Date	:	04/30/2024

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