Provider Demographics
NPI:1255995155
Name:JEAN, ALICE (MD, MPH, DIPABLM)
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:
Last Name:JEAN
Suffix:
Gender:F
Credentials:MD, MPH, DIPABLM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1921 STONECIPHER BLVD
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-3439
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1921 STONECIPHER BLVD
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-3439
Practice Address - Country:US
Practice Address - Phone:580-426-3980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-25
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUTLL-2022-003207Q00000X
CAA182562207Q00000X
TXV1799207Q00000X
OK41283207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine