Provider Demographics
NPI:1104205186
Name:JENISTA, JODI (APRN-CNP)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:JENISTA
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 30589
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73140-3589
Mailing Address - Country:US
Mailing Address - Phone:405-769-3301
Mailing Address - Fax:
Practice Address - Street 1:130 N BROADWAY AVE STE 300
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74801-6939
Practice Address - Country:US
Practice Address - Phone:405-395-0399
Practice Address - Fax:405-395-0330
Is Sole Proprietor?:No
Enumeration Date:2015-05-24
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK89504363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK89504OtherSTATE LICENSE