Provider Demographics
NPI:1720711252
Name:CANTRELL, JESSICA NICOLE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:NICOLE
Last Name:CANTRELL
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 1:7146 WALTON LN
Mailing Address - Street 2:
Mailing Address - City:MCLOUD
Mailing Address - State:OK
Mailing Address - Zip Code:74851-8185
Mailing Address - Country:US
Mailing Address - Phone:405-432-7658
Mailing Address - Fax:
Practice Address - Street 1:7146 WALTON LN
Practice Address - Street 2:
Practice Address - City:MCLOUD
Practice Address - State:OK
Practice Address - Zip Code:74851-8185
Practice Address - Country:US
Practice Address - Phone:405-432-7658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-01
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No175T00000XOther Service ProvidersPeer Specialist