Provider Demographics
NPI:1902106768
Name:LANDRETH, JAKE WESLEY (DC)
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:WESLEY
Last Name:LANDRETH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12707 E 86TH ST N
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-2506
Mailing Address - Country:US
Mailing Address - Phone:918-272-7432
Mailing Address - Fax:918-272-7448
Practice Address - Street 1:12707 E 86TH ST N
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-2506
Practice Address - Country:US
Practice Address - Phone:918-272-7432
Practice Address - Fax:918-272-7448
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-27
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4002111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor