Provider Demographics
NPI:1144956681
Name:WASHINGTON, JENNIE SHAE
Entity type:Individual
Prefix:
First Name:JENNIE
Middle Name:SHAE
Last Name:WASHINGTON
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 1:19839 W 864 RD
Mailing Address - Street 2:
Mailing Address - City:PARK HILL
Mailing Address - State:OK
Mailing Address - Zip Code:74451-3015
Mailing Address - Country:US
Mailing Address - Phone:918-718-1980
Mailing Address - Fax:
Practice Address - Street 1:1323 W KEETOOWAH ST
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-3462
Practice Address - Country:US
Practice Address - Phone:918-506-6901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-27
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist