Provider Demographics
NPI:1134104862
Name:CHITWOOD, JENNY LYNN (MPT)
Entity Type:Individual
Prefix:MS
First Name:JENNY
Middle Name:LYNN
Last Name:CHITWOOD
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38271 HARMON RD
Mailing Address - Street 2:
Mailing Address - City:WISTER
Mailing Address - State:OK
Mailing Address - Zip Code:74966-2707
Mailing Address - Country:US
Mailing Address - Phone:918-649-0405
Mailing Address - Fax:918-647-0403
Practice Address - Street 1:24456 KERR RD
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-8163
Practice Address - Country:US
Practice Address - Phone:918-649-0405
Practice Address - Fax:918-647-0403
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-15
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3661225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200064390AMedicaid