Provider Demographics
NPI:1497561237
Name:ANDERSON, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:162948 N 4346 LN
Mailing Address - Street 2:
Mailing Address - City:TUSKAHOMA
Mailing Address - State:OK
Mailing Address - Zip Code:74574-5917
Mailing Address - Country:US
Mailing Address - Phone:918-415-4596
Mailing Address - Fax:
Practice Address - Street 1:904 DALLAS ST
Practice Address - Street 2:
Practice Address - City:TALIHINA
Practice Address - State:OK
Practice Address - Zip Code:74571
Practice Address - Country:US
Practice Address - Phone:918-942-1033
Practice Address - Fax:918-574-6150
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-06
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator