Provider Demographics
NPI:1073905626
Name:SIDES, JENNIE GAYLE
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:GAYLE
Last Name:SIDES
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:JENNIE
Other - Middle Name:GAYLE
Other - Last Name:SADLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8109 HIGHWAY 30
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:OK
Mailing Address - Zip Code:73642-4256
Mailing Address - Country:US
Mailing Address - Phone:580-799-7746
Mailing Address - Fax:
Practice Address - Street 1:8109 HIGHWAY 30
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:OK
Practice Address - Zip Code:73642-4256
Practice Address - Country:US
Practice Address - Phone:580-799-7746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-19
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist