Provider Demographics
NPI:1558998377
Name:SHIELDS, JENNIFER DAER (PHD, HEC-C)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:DAER
Last Name:SHIELDS
Suffix:
Gender:F
Credentials:PHD, HEC-C
Other - Prefix:DR
Other - First Name:JENNY
Other - Middle Name:DAER
Other - Last Name:SHIELDS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:17121 BEDFORD DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-6867
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4300 W MEMORIAL RD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-8304
Practice Address - Country:US
Practice Address - Phone:405-752-3840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-23
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1359103TC0700X
103T00000X
OK129889174V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174V00000XOther Service ProvidersClinical Ethicist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1558998377Medicaid