Basic Information
| Provider Information | |||||||||
| NPI: | 1386093672 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATHEW | ||||||||
| FirstName: | JENNIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1921 STONECIPHER DR | ||||||||
| Address2: | |||||||||
| City: | ADA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748203439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804363980 | ||||||||
| FaxNumber: | 5804216283 | ||||||||
| Practice Location | |||||||||
| Address1: | 1921 STONECIPHER DR | ||||||||
| Address2: | |||||||||
| City: | ADA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748203439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804363980 | ||||||||
| FaxNumber: | 5804216283 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2016 | ||||||||
| LastUpdateDate: | 04/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MT211153 | PA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 34728 | OK | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.