Provider Demographics
NPI:1114599081
Name:PETTIT, JENNIFER (APRN)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:PETTIT
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10929 OLD HIGHWAY 71
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72916-8160
Mailing Address - Country:US
Mailing Address - Phone:479-250-1562
Mailing Address - Fax:
Practice Address - Street 1:100 WOODLAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:ROLAND
Practice Address - State:OK
Practice Address - Zip Code:74954-5213
Practice Address - Country:US
Practice Address - Phone:918-503-6464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-12
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK203920363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR288261758Medicaid