Provider Demographics
NPI:1598902454
Name:LAM, JENNI RAE (PT ASSISTANT)
Entity Type:Individual
Prefix:MRS
First Name:JENNI
Middle Name:RAE
Last Name:LAM
Suffix:
Gender:F
Credentials:PT ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13800 N BOOMER RD
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73703-2108
Mailing Address - Country:US
Mailing Address - Phone:580-554-0501
Mailing Address - Fax:
Practice Address - Street 1:705 5TH ST
Practice Address - Street 2:KREMLIN PUBLIC SCHOOLS
Practice Address - City:KREMLIN
Practice Address - State:OK
Practice Address - Zip Code:73753
Practice Address - Country:US
Practice Address - Phone:580-874-2284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-14
Last Update Date:2009-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK570225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant