Provider Demographics
NPI:1427367952
Name:MILSAP, JENNIFER (MOT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MILSAP
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6800 NW 39TH EXPY
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:OK
Mailing Address - Zip Code:73008-2513
Mailing Address - Country:US
Mailing Address - Phone:405-440-9866
Mailing Address - Fax:405-440-9341
Practice Address - Street 1:6800 NW 39TH EXPY
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:OK
Practice Address - Zip Code:73008-2513
Practice Address - Country:US
Practice Address - Phone:405-440-9866
Practice Address - Fax:405-440-9341
Is Sole Proprietor?:No
Enumeration Date:2010-10-01
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1669225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200307270AMedicaid