Provider Demographics
NPI:1871033894
Name:CARPER, JESSE (PTA)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:CARPER
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36488 S HIGHWAY 82
Mailing Address - Street 2:
Mailing Address - City:VINITA
Mailing Address - State:OK
Mailing Address - Zip Code:74301-7438
Mailing Address - Country:US
Mailing Address - Phone:918-256-0381
Mailing Address - Fax:918-782-2855
Practice Address - Street 1:36488 S HIGHWAY 82
Practice Address - Street 2:
Practice Address - City:VINITA
Practice Address - State:OK
Practice Address - Zip Code:74301-7438
Practice Address - Country:US
Practice Address - Phone:918-256-0381
Practice Address - Fax:918-782-2855
Is Sole Proprietor?:No
Enumeration Date:2017-02-24
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2302225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant