Provider Demographics
NPI:1285809632
Name:HANSLICK, JENNIFER L (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:HANSLICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1120 S UTICA AVE
Mailing Address - Street 2:SUITE 2123
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104
Mailing Address - Country:US
Mailing Address - Phone:918-579-5402
Mailing Address - Fax:918-579-5404
Practice Address - Street 1:1120 S UTICA AVE
Practice Address - Street 2:SUITE 2123
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4012
Practice Address - Country:US
Practice Address - Phone:918-579-5402
Practice Address - Fax:918-579-5404
Is Sole Proprietor?:No
Enumeration Date:2008-04-28
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2009012792208000000X, 2080N0001X
ORMD1774512080N0001X
OK326352080N0001X
CO495292080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200673240AMedicaid
CO50271768Medicaid