Provider Demographics
NPI:1619220266
Name:PARKER, JEROME ANTONIE
Entity Type:Individual
Prefix:MR
First Name:JEROME
Middle Name:ANTONIE
Last Name:PARKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 N LAIRD AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73105-7628
Mailing Address - Country:US
Mailing Address - Phone:405-213-8158
Mailing Address - Fax:
Practice Address - Street 1:3101 N LAIRD AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73105-7628
Practice Address - Country:US
Practice Address - Phone:405-213-8158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-19
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK390200000X
OKR080262296390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program