Provider Demographics
NPI:1548730559
Name:STICKELMEYER, JENNIFER LYN
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYN
Last Name:STICKELMEYER
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 1:22272 E 730 RD
Mailing Address - Street 2:
Mailing Address - City:WAGONER
Mailing Address - State:OK
Mailing Address - Zip Code:74467-6837
Mailing Address - Country:US
Mailing Address - Phone:918-694-9766
Mailing Address - Fax:
Practice Address - Street 1:505 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PORTER
Practice Address - State:OK
Practice Address - Zip Code:74454-1015
Practice Address - Country:US
Practice Address - Phone:918-483-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-03
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0069196363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKH081616683OtherDRIVERS LICENSE