Provider Demographics
NPI:1730311986
Name:DOUGLASS, JANE SUSAN (MED CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:JANE
Middle Name:SUSAN
Last Name:DOUGLASS
Suffix:
Gender:F
Credentials:MED CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 N AIR DEPOT BLVD
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-7625
Mailing Address - Country:US
Mailing Address - Phone:405-340-1534
Mailing Address - Fax:
Practice Address - Street 1:2121 N AIR DEPOT BLVD
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-7625
Practice Address - Country:US
Practice Address - Phone:405-340-1534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-20
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK657235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist