Provider Demographics
NPI:1265895528
Name:WHITEHEAD, JADE NICOLE (PTA)
Entity type:Individual
Prefix:
First Name:JADE
Middle Name:NICOLE
Last Name:WHITEHEAD
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3030 NW EXPRESSWAY
Mailing Address - Street 2:SUITE 809
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-5474
Mailing Address - Country:US
Mailing Address - Phone:866-848-8813
Mailing Address - Fax:
Practice Address - Street 1:3030 NW EXPRESSWAY
Practice Address - Street 2:SUITE 809
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-5474
Practice Address - Country:US
Practice Address - Phone:866-848-8813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-03
Last Update Date:2016-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1911225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant