Provider Demographics
NPI:1508248089
Name:WHITENER, HENRY JAKE (DO)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:JAKE
Last Name:WHITENER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19600 E ROSS ST
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-0545
Mailing Address - Country:US
Mailing Address - Phone:539-234-1000
Mailing Address - Fax:
Practice Address - Street 1:19600 E ROSS ST
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-0545
Practice Address - Country:US
Practice Address - Phone:539-234-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-22
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OK6072208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program