Provider Demographics
NPI:1083043335
Name:NICEK, JENETTE LOUISE
Entity Type:Individual
Prefix:
First Name:JENETTE
Middle Name:LOUISE
Last Name:NICEK
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 1:5805 NW 116TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73162-2038
Mailing Address - Country:US
Mailing Address - Phone:405-315-1709
Mailing Address - Fax:
Practice Address - Street 1:5805 NW 116TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73162-2038
Practice Address - Country:US
Practice Address - Phone:405-315-1709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-07
Last Update Date:2019-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10132183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist