Provider Demographics
NPI:1104638972
Name:EDENS, JESSICA LEEANN (LMT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEEANN
Last Name:EDENS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4901 SE 139TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73165-7422
Mailing Address - Country:US
Mailing Address - Phone:405-651-3625
Mailing Address - Fax:
Practice Address - Street 1:4901 SE 139TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73165-7422
Practice Address - Country:US
Practice Address - Phone:405-651-3626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-21
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK157407225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist