Provider Demographics
NPI:1518525849
Name:MONTGOMERY, JAYME KENNA (CNP)
Entity Type:Individual
Prefix:
First Name:JAYME
Middle Name:KENNA
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8505 E 132ND ST S
Mailing Address - Street 2:
Mailing Address - City:BIXBY
Mailing Address - State:OK
Mailing Address - Zip Code:74008-3306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:705 W OAKLAND ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-1656
Practice Address - Country:US
Practice Address - Phone:918-251-2666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-01
Last Update Date:2019-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK113779363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily