Basic Information
| Provider Information | |||||||||
| NPI: | 1184227514 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARDAGE | ||||||||
| FirstName: | JO | ||||||||
| MiddleName: | LYN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5310 E 31ST ST | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741355018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186003100 | ||||||||
| FaxNumber: | 9185601399 | ||||||||
| Practice Location | |||||||||
| Address1: | 2601 E 5TH PL | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741042905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9188339900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2020 | ||||||||
| LastUpdateDate: | 07/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | Y | Other Service Providers | Community Health Worker |
No ID Information.