Provider Demographics
NPI:1659735710
Name:PEMBROOK, JARED
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:
Last Name:PEMBROOK
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 1:5300 N INDEPENDENCE AVE STE 280
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-5555
Mailing Address - Country:US
Mailing Address - Phone:405-945-4589
Mailing Address - Fax:405-945-4381
Practice Address - Street 1:3400 NW EXPRESSWAY STE 500
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4492
Practice Address - Country:US
Practice Address - Phone:405-945-4589
Practice Address - Fax:405-945-4381
Is Sole Proprietor?:No
Enumeration Date:2016-04-05
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK32214207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine