Basic Information
| Provider Information | |||||||||
| NPI: | 1427125194 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ODELL-MILLER | ||||||||
| FirstName: | JACKIE | ||||||||
| MiddleName: | JENE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 15951 LITTLE AXE DR | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730269088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054470300 | ||||||||
| FaxNumber: | 4057017914 | ||||||||
| Practice Location | |||||||||
| Address1: | 15951 LITTLE AXE DR | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730269088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054470300 | ||||||||
| FaxNumber: | 4057017914 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2006 | ||||||||
| LastUpdateDate: | 02/04/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | R0044689 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 200100070A | 05 | OK | MEDICAID | R0044689 | 01 | OK | STATE LICENSE NUMBER | OTHER |