Provider Demographics
NPI:1124622337
Name:STOUTZENBERGER, JILLIAN
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:STOUTZENBERGER
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 1:101 E HALL OF FAME AVE
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74075-5425
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 E HALL OF FAME AVE
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74075-5425
Practice Address - Country:US
Practice Address - Phone:405-707-0287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-28
Last Update Date:2020-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18495183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist