Provider Demographics
NPI:1932883402
Name:MOSQUITO, JEREAN
Entity Type:Individual
Prefix:
First Name:JEREAN
Middle Name:
Last Name:MOSQUITO
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 1:19135 BALD HILL RD
Mailing Address - Street 2:
Mailing Address - City:OKMULGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74447-9399
Mailing Address - Country:US
Mailing Address - Phone:918-777-8136
Mailing Address - Fax:
Practice Address - Street 1:10212 E 41ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74146-3703
Practice Address - Country:US
Practice Address - Phone:918-960-7852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator