Provider Demographics
NPI:1972003671
Name:KING, JENNIFER DAWN
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DAWN
Last Name:KING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2326 N BENJAMIN ST
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74075-6136
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 S OAKWOOD RD
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703-4918
Practice Address - Country:US
Practice Address - Phone:580-237-7625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-19
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1209225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant