Provider Demographics
NPI:1952761926
Name:SMALLWOOD, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SMALLWOOD
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:PO BOX 119
Mailing Address - Street 2:
Mailing Address - City:PEGGS
Mailing Address - State:OK
Mailing Address - Zip Code:74452-0119
Mailing Address - Country:US
Mailing Address - Phone:918-598-3412
Mailing Address - Fax:
Practice Address - Street 1:10821 WEST HICKORY AVENUE
Practice Address - Street 2:PEGGS SCHOOL
Practice Address - City:PEGGS
Practice Address - State:OK
Practice Address - Zip Code:74452
Practice Address - Country:US
Practice Address - Phone:918-260-0199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-03
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK047434244Medicaid