MEDICARE: J K AT HOME

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	363L00000X	Nurse Practitioner
2	207QG0300X	Geriatric Medicine (Family Medicine) Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1811607690
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	J K AT HOME

Provider Business Mailing Address
First Line	:	2237 W MEMORIAL RD STE 112
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73134-8064
Country	:	US
Telephone Number	:	405-808-3714
Fax Number	:

Provider Business Practice Location Address
First Line	:	2237 W MEMORIAL RD STE 112
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73134-8064
Country	:	US
Telephone Number	:	405-808-3714
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JILLIAN HERNDON
Credential	:
Telephone Number	:	405-808-3714

Provider Enumeration Date	:	12/01/2022
Last Update Date	:	04/06/2023

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Directions to “J K AT HOME ” Practice Location

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