Provider Demographics
NPI:1346793924
Name:GUMBS, JERMEKA
Entity Type:Individual
Prefix:
First Name:JERMEKA
Middle Name:
Last Name:GUMBS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7777 S LEWIS AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74171-0001
Mailing Address - Country:US
Mailing Address - Phone:352-301-0127
Mailing Address - Fax:
Practice Address - Street 1:11740 E 21ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74129-1820
Practice Address - Country:US
Practice Address - Phone:918-437-9495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-29
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program