Provider Demographics
NPI:1952878472
Name:JERSEY, COURTNEY NICOLE (PA)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:NICOLE
Last Name:JERSEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 W I 35 FRONTAGE RD
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-8515
Mailing Address - Country:US
Mailing Address - Phone:405-757-3365
Mailing Address - Fax:405-757-3499
Practice Address - Street 1:2301 W I 35 FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-8515
Practice Address - Country:US
Practice Address - Phone:405-757-3365
Practice Address - Fax:405-757-3499
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-02
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA12364363AM0700X
OK4390363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical