Provider Demographics
NPI:1366775611
Name:PUTNAM, JENNIFER ROBIN (PA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ROBIN
Last Name:PUTNAM
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:8 SW 89TH ST
Mailing Address - Street 2:STE 100
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73139-8534
Mailing Address - Country:US
Mailing Address - Phone:405-455-3322
Mailing Address - Fax:405-606-4338
Practice Address - Street 1:1342 S DOUGLAS BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73130-5215
Practice Address - Country:US
Practice Address - Phone:405-455-3322
Practice Address - Fax:405-455-3358
Is Sole Proprietor?:No
Enumeration Date:2009-09-17
Last Update Date:2017-02-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OK2115363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
208362023OtherGROUP TAX-ID