Provider Demographics
NPI:1710402946
Name:CHEATHAM, JENNIFER LYNN (MS)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:CHEATHAM
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 N HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-4022
Mailing Address - Country:US
Mailing Address - Phone:405-395-2602
Mailing Address - Fax:
Practice Address - Street 1:1605 N HARRISON ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-4022
Practice Address - Country:US
Practice Address - Phone:405-395-2602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-09
Last Update Date:2017-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty