Provider Demographics
NPI:1710234356
Name:SMALLWOOD, JENNA MARIE (MS,CCC-SLP)
Entity Type:Individual
Prefix:MISS
First Name:JENNA
Middle Name:MARIE
Last Name:SMALLWOOD
Suffix:
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 66 BOX 765
Mailing Address - Street 2:
Mailing Address - City:SAWYER
Mailing Address - State:OK
Mailing Address - Zip Code:74756-9768
Mailing Address - Country:US
Mailing Address - Phone:580-298-7314
Mailing Address - Fax:
Practice Address - Street 1:HC 66 BOX 765
Practice Address - Street 2:
Practice Address - City:SAWYER
Practice Address - State:OK
Practice Address - Zip Code:74756-9768
Practice Address - Country:US
Practice Address - Phone:580-298-7314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-14
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3638235Z00000X
12153844235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
12153844OtherASHA
OK3638OtherOBESPA