Provider Demographics
NPI:1275568115
Name:JENNINGS, BEAU CHARLES (DO)
Entity Type:Individual
Prefix:DR
First Name:BEAU
Middle Name:CHARLES
Last Name:JENNINGS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1551 N 9TH ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-8898
Mailing Address - Country:US
Mailing Address - Phone:918-455-3627
Mailing Address - Fax:918-355-7949
Practice Address - Street 1:1551 N 9TH ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-8898
Practice Address - Country:US
Practice Address - Phone:918-455-3627
Practice Address - Fax:918-355-7949
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2014-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2173207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100118100BMedicaid
E09850Medicare UPIN
OK100118100BMedicaid