Provider Demographics
NPI:1144239229
Name:BERENDS, JENNIFER L (DO)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:BERENDS
Suffix:
Gender:F
Credentials:DO
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 703
Mailing Address - Street 2:
Mailing Address - City:SHATTUCK
Mailing Address - State:OK
Mailing Address - Zip Code:73858-0703
Mailing Address - Country:US
Mailing Address - Phone:580-938-5275
Mailing Address - Fax:580-938-2256
Practice Address - Street 1:416 S MAIN
Practice Address - Street 2:
Practice Address - City:SHATTUCK
Practice Address - State:OK
Practice Address - Zip Code:73858-0703
Practice Address - Country:US
Practice Address - Phone:580-938-5275
Practice Address - Fax:580-938-2256
Is Sole Proprietor?:No
Enumeration Date:2006-08-06
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4504207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200119230AMedicaid
OKOK402635Medicare PIN
OK200119230AMedicaid