Provider Demographics
NPI:1184702359
Name:MIKES, JENNY REBECCA (MS RD LD)
Entity type:Individual
Prefix:MRS
First Name:JENNY
Middle Name:REBECCA
Last Name:MIKES
Suffix:
Gender:F
Credentials:MS RD LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8512 TIFFANY DRIVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73132
Mailing Address - Country:US
Mailing Address - Phone:405-659-2805
Mailing Address - Fax:405-728-2402
Practice Address - Street 1:8512 TIFFANY DRIVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73132
Practice Address - Country:US
Practice Address - Phone:405-659-2805
Practice Address - Fax:405-728-2402
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1107133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200012100AMedicaid
OK200012100AMedicaid