Provider Demographics
NPI:1902035207
Name:LITTLEJOHN, MICAH JEROD (PTA)
Entity Type:Individual
Prefix:MR
First Name:MICAH
Middle Name:JEROD
Last Name:LITTLEJOHN
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 1:616 MEADOWLARK LN
Mailing Address - Street 2:
Mailing Address - City:COMMERCE
Mailing Address - State:OK
Mailing Address - Zip Code:74339-3147
Mailing Address - Country:US
Mailing Address - Phone:918-533-4292
Mailing Address - Fax:
Practice Address - Street 1:715 N BREWER ST
Practice Address - Street 2:
Practice Address - City:VINITA
Practice Address - State:OK
Practice Address - Zip Code:74301-1426
Practice Address - Country:US
Practice Address - Phone:918-256-9207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-08
Last Update Date:2009-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1741225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant