Provider Demographics
NPI:1104396266
Name:RICHARDSON, JENNIFER LEEANN
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEEANN
Last Name:RICHARDSON
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 1:712 S WEWOKA AVE
Mailing Address - Street 2:
Mailing Address - City:WEWOKA
Mailing Address - State:OK
Mailing Address - Zip Code:74884-3243
Mailing Address - Country:US
Mailing Address - Phone:405-683-4136
Mailing Address - Fax:
Practice Address - Street 1:35859 E.W. 1210
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:OK
Practice Address - Zip Code:74868
Practice Address - Country:US
Practice Address - Phone:405-220-6207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-03
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty