Provider Demographics
NPI:1568784957
Name:CHILDE, JESSICA REY (DO)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:REY
Last Name:CHILDE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4802 S 109TH EAST AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74146-5822
Mailing Address - Country:US
Mailing Address - Phone:918-392-1400
Mailing Address - Fax:918-392-1488
Practice Address - Street 1:4802 S 109TH EAST AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74146-5822
Practice Address - Country:US
Practice Address - Phone:918-392-1400
Practice Address - Fax:918-392-1488
Is Sole Proprietor?:No
Enumeration Date:2010-02-25
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5910207XS0106X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200649470AMedicaid
OK200649470AMedicaid