Provider Demographics
NPI:1073128054
Name:WOOD, JENNIFER DIANE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DIANE
Last Name:WOOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28615 E 141ST ST S APT 96
Mailing Address - Street 2:
Mailing Address - City:COWETA
Mailing Address - State:OK
Mailing Address - Zip Code:74429-7594
Mailing Address - Country:US
Mailing Address - Phone:918-370-6068
Mailing Address - Fax:
Practice Address - Street 1:308 N ASPEN AVE
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-2205
Practice Address - Country:US
Practice Address - Phone:539-777-0940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-15
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician