Provider Demographics
NPI:1629269154
Name:LOVE, JERMAINE QUENTIN (PT)
Entity Type:Individual
Prefix:MR
First Name:JERMAINE
Middle Name:QUENTIN
Last Name:LOVE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12004 CAMELOT PL
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-6722
Mailing Address - Country:US
Mailing Address - Phone:405-812-2082
Mailing Address - Fax:
Practice Address - Street 1:12004 CAMELOT PL
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-6722
Practice Address - Country:US
Practice Address - Phone:405-812-2082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-08
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3142225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist