Provider Demographics
NPI:1003384546
Name:PRIDE, JOVAN (OT)
Entity Type:Individual
Prefix:
First Name:JOVAN
Middle Name:
Last Name:PRIDE
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14715 BRISTOL PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-1894
Mailing Address - Country:US
Mailing Address - Phone:405-840-1686
Mailing Address - Fax:405-840-1006
Practice Address - Street 1:5701 SE 74TH ST STE G
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73135-1104
Practice Address - Country:US
Practice Address - Phone:405-610-1909
Practice Address - Fax:405-610-1910
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-02
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5279225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200802530AMedicaid