Provider Demographics
NPI:1376264358
Name:ROGERS, JESSE
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:ROGERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 FAIRMONT RD
Mailing Address - Street 2:
Mailing Address - City:VINITA
Mailing Address - State:OK
Mailing Address - Zip Code:74301-2712
Mailing Address - Country:US
Mailing Address - Phone:918-244-5446
Mailing Address - Fax:
Practice Address - Street 1:102 FAIRMONT RD
Practice Address - Street 2:
Practice Address - City:VINITA
Practice Address - State:OK
Practice Address - Zip Code:74301-2712
Practice Address - Country:US
Practice Address - Phone:918-244-5446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-07
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty