Provider Demographics
NPI:1063584100
Name:WOLFE, JACE A (PHD)
Entity type:Individual
Prefix:
First Name:JACE
Middle Name:A
Last Name:WOLFE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11500 N PORTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-4625
Mailing Address - Country:US
Mailing Address - Phone:405-548-4300
Mailing Address - Fax:
Practice Address - Street 1:11500 N PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-4625
Practice Address - Country:US
Practice Address - Phone:405-548-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2017-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK281231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100656370AMedicaid
OK100656370BMedicaid
OK100656370BMedicaid