Provider Demographics
NPI:1013746437
Name:JENKINS, OLIVIA CHALISE
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:CHALISE
Last Name:JENKINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:OLIVIA
Other - Middle Name:CHALISE
Other - Last Name:WAGONER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:510 E MEMORIAL RD STE C1
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73114-2218
Mailing Address - Country:US
Mailing Address - Phone:405-383-9001
Mailing Address - Fax:
Practice Address - Street 1:510 E MEMORIAL RD STE C1
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73114-2218
Practice Address - Country:US
Practice Address - Phone:405-383-9001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-01
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician