Provider Demographics
NPI:1407399496
Name:BOATMAN, JALISHA
Entity Type:Individual
Prefix:
First Name:JALISHA
Middle Name:
Last Name:BOATMAN
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 1:813 NE 25TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73105-7938
Mailing Address - Country:US
Mailing Address - Phone:405-858-2700
Mailing Address - Fax:405-858-1776
Practice Address - Street 1:2617 GENERAL PERSHING BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73107-6437
Practice Address - Country:US
Practice Address - Phone:405-858-2700
Practice Address - Fax:405-858-1776
Is Sole Proprietor?:No
Enumeration Date:2016-11-23
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist