Provider Demographics
NPI:1831965763
Name:WISENER, JENNIFER WRAY
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:WRAY
Last Name:WISENER
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 1:561 N 4250 RD
Mailing Address - Street 2:
Mailing Address - City:HUGO
Mailing Address - State:OK
Mailing Address - Zip Code:74743-3658
Mailing Address - Country:US
Mailing Address - Phone:580-372-0499
Mailing Address - Fax:
Practice Address - Street 1:1005 S 5TH ST BLDG 4
Practice Address - Street 2:
Practice Address - City:HUGO
Practice Address - State:OK
Practice Address - Zip Code:74743-8013
Practice Address - Country:US
Practice Address - Phone:580-372-0499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-01
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist