Provider Demographics
NPI:1073257093
Name:EAGLES NEST PEDIATRIC THERAPY
Entity Type:Organization
Organization Name:EAGLES NEST PEDIATRIC THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:FITZPATRICK
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:405-623-9178
Mailing Address - Street 1:14700 SHARON SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:JONES
Mailing Address - State:OK
Mailing Address - Zip Code:73049-8700
Mailing Address - Country:US
Mailing Address - Phone:405-623-9178
Mailing Address - Fax:
Practice Address - Street 1:14700 SHARON SPRINGS DR
Practice Address - Street 2:
Practice Address - City:JONES
Practice Address - State:OK
Practice Address - Zip Code:73049-8700
Practice Address - Country:US
Practice Address - Phone:405-623-9178
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-26
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1538279229OtherINDIVIDUAL NPI
OK1593OtherOKLAHOMA MEDICAL LICENSURE BOARD