Provider Demographics
NPI:1215947676
Name:JAYNE, SANDY K (PT)
Entity type:Individual
Prefix:MRS
First Name:SANDY
Middle Name:K
Last Name:JAYNE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5622 N PORTLAND AVE
Mailing Address - Street 2:#250
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-2096
Mailing Address - Country:US
Mailing Address - Phone:405-946-4150
Mailing Address - Fax:405-946-4150
Practice Address - Street 1:5622 N PORTLAND AVE
Practice Address - Street 2:#250
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-2096
Practice Address - Country:US
Practice Address - Phone:405-946-4150
Practice Address - Fax:405-946-4150
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK492225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2248268Medicaid
OHJA4045941Medicare ID - Type UnspecifiedPHYSICAL THERAPY