Provider Demographics
NPI:1184734295
Name:GREATHOUSE, JANNA (MS CCC SLP)
Entity type:Individual
Prefix:
First Name:JANNA
Middle Name:
Last Name:GREATHOUSE
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11108 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-2061
Mailing Address - Country:US
Mailing Address - Phone:918-504-4895
Mailing Address - Fax:
Practice Address - Street 1:11108 S 2ND ST
Practice Address - Street 2:
Practice Address - City:JENKS
Practice Address - State:OK
Practice Address - Zip Code:74037-2061
Practice Address - Country:US
Practice Address - Phone:918-504-4895
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3304235Z00000X
OK3302235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA0596Medicaid