MEDICARE: JO LYN HARDAGE

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	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1184227514
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JO LYN HARDAGE

Provider Business Mailing Address
First Line	:	5310 E 31ST ST
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74135-5018
Country	:	US
Telephone Number	:	918-600-3100
Fax Number	:	918-560-1399

Provider Business Practice Location Address
First Line	:	2601 E 5TH PL
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74104-2905
Country	:	US
Telephone Number	:	918-833-9900
Fax Number	:

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

Provider Enumeration Date	:	11/18/2020
Last Update Date	:	07/26/2021

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