Provider Demographics
NPI:1447596358
Name:PAYNE, JACQUELYN DOVE (PTA)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:DOVE
Last Name:PAYNE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4049 E 23RD ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74114-3431
Mailing Address - Country:US
Mailing Address - Phone:918-510-1270
Mailing Address - Fax:
Practice Address - Street 1:4300 W HOUSTON ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-4519
Practice Address - Country:US
Practice Address - Phone:918-307-0233
Practice Address - Fax:918-307-0233
Is Sole Proprietor?:No
Enumeration Date:2012-12-20
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK417225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant