Provider Demographics
NPI:1366876542
Name:NOVIELLO, JENNIFER MARIE
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MARIE
Last Name:NOVIELLO
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 1:134 NE FULLERTON ST
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73507-1455
Mailing Address - Country:US
Mailing Address - Phone:580-284-4496
Mailing Address - Fax:
Practice Address - Street 1:1200 NE 13TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73117-1022
Practice Address - Country:US
Practice Address - Phone:405-522-3908
Practice Address - Fax:405-522-3650
Is Sole Proprietor?:No
Enumeration Date:2013-08-24
Last Update Date:2013-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator