Provider Demographics
NPI:1336458215
Name:JEAN E FORSBERG PLLC
Entity Type:Organization
Organization Name:JEAN E FORSBERG PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:ROSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHEADLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-705-2644
Mailing Address - Street 1:PO BOX 268996
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73126-8996
Mailing Address - Country:US
Mailing Address - Phone:405-705-0018
Mailing Address - Fax:405-705-0029
Practice Address - Street 1:1801 W 3RD ST
Practice Address - Street 2:
Practice Address - City:ELK CITY
Practice Address - State:OK
Practice Address - Zip Code:73644-5145
Practice Address - Country:US
Practice Address - Phone:580-225-2511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-27
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK37D0472420291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200317000AMedicaid