Provider Demographics
NPI:1598496051
Name:GRAYSON, JESSICA ROBIN
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ROBIN
Last Name:GRAYSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13648 KENOSHA AVE
Mailing Address - Street 2:
Mailing Address - City:GLENPOOL
Mailing Address - State:OK
Mailing Address - Zip Code:74033-3829
Mailing Address - Country:US
Mailing Address - Phone:918-807-8083
Mailing Address - Fax:
Practice Address - Street 1:1125 S TRENTON AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74120-5418
Practice Address - Country:US
Practice Address - Phone:918-579-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-23
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK206537364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist