Provider Demographics
NPI:1245223643
Name:EVENSEN, JANA MCCULLOUGH (DPH)
Entity Type:Individual
Prefix:MRS
First Name:JANA
Middle Name:MCCULLOUGH
Last Name:EVENSEN
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17841 W 879 RD
Mailing Address - Street 2:
Mailing Address - City:PARK HILL
Mailing Address - State:OK
Mailing Address - Zip Code:74451-2273
Mailing Address - Country:US
Mailing Address - Phone:918-457-5275
Mailing Address - Fax:
Practice Address - Street 1:1301 E DOWNING ST
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-3350
Practice Address - Country:US
Practice Address - Phone:918-456-1000
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12811183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist