Provider Demographics
NPI:1003111972
Name:LUETKEMEYER, JESSICA LEE (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEE
Last Name:LUETKEMEYER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LEE
Other - Last Name:HEITERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4502 E 41ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-2536
Mailing Address - Country:US
Mailing Address - Phone:186-194-4009
Mailing Address - Fax:
Practice Address - Street 1:1111 S SAINT LOUIS AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74120-5440
Practice Address - Country:US
Practice Address - Phone:918-619-4400
Practice Address - Fax:918-619-4696
Is Sole Proprietor?:No
Enumeration Date:2011-01-24
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1960363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200318540AMedicaid