Provider Demographics
NPI:1356782304
Name:BENTLEY, JAYNE ANN
Entity type:Individual
Prefix:
First Name:JAYNE
Middle Name:ANN
Last Name:BENTLEY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 W 3RD ST STE 100
Mailing Address - Street 2:
Mailing Address - City:ELK CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73644-5160
Mailing Address - Country:US
Mailing Address - Phone:580-339-8001
Mailing Address - Fax:580-339-8031
Practice Address - Street 1:1800 W 1ST ST STE 102
Practice Address - Street 2:
Practice Address - City:ELK CITY
Practice Address - State:OK
Practice Address - Zip Code:73644-3133
Practice Address - Country:US
Practice Address - Phone:580-225-2515
Practice Address - Fax:580-303-5850
Is Sole Proprietor?:No
Enumeration Date:2013-07-07
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK88982363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200511070AMedicaid