Provider Demographics
NPI:1730556218
Name:HORNE, JACIE E (MPT)
Entity type:Individual
Prefix:
First Name:JACIE
Middle Name:E
Last Name:HORNE
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:JACIE
Other - Middle Name:E
Other - Last Name:FITE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MPT
Mailing Address - Street 1:14 E AYERS ST
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-3667
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14 E AYERS ST
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-3667
Practice Address - Country:US
Practice Address - Phone:405-513-8186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-31
Last Update Date:2015-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4135225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200584160AMedicaid