Provider Demographics
NPI:1528377116
Name:PHAM, JENNIFER (DPH)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:PHAM
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:LE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4913 W RENO AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73127-6339
Mailing Address - Country:US
Mailing Address - Phone:405-948-4900
Mailing Address - Fax:405-948-4929
Practice Address - Street 1:4913 W RENO AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73127-6339
Practice Address - Country:US
Practice Address - Phone:405-948-4900
Practice Address - Fax:405-948-4929
Is Sole Proprietor?:No
Enumeration Date:2010-09-29
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK14218183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist