Provider Demographics
NPI:1720225741
Name:WHITE, JERRI SUZETTE (RCP)
Entity Type:Individual
Prefix:
First Name:JERRI
Middle Name:SUZETTE
Last Name:WHITE
Suffix:
Gender:F
Credentials:RCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 529
Mailing Address - Street 2:
Mailing Address - City:WARNER
Mailing Address - State:OK
Mailing Address - Zip Code:74469-0529
Mailing Address - Country:US
Mailing Address - Phone:918-463-2055
Mailing Address - Fax:918-463-2032
Practice Address - Street 1:738 8TH ST
Practice Address - Street 2:
Practice Address - City:WARNER
Practice Address - State:OK
Practice Address - Zip Code:74469-2005
Practice Address - Country:US
Practice Address - Phone:918-463-2055
Practice Address - Fax:918-463-2032
Is Sole Proprietor?:No
Enumeration Date:2009-01-13
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK620227800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Certified
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK332B00000XMedicaid