Provider Demographics
NPI:1336962497
Name:LANE, JESSICA DIANA
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:DIANA
Last Name:LANE
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 1:16787 SE 27TH ST
Mailing Address - Street 2:
Mailing Address - City:CHOCTAW
Mailing Address - State:OK
Mailing Address - Zip Code:73020-6446
Mailing Address - Country:US
Mailing Address - Phone:405-618-0079
Mailing Address - Fax:
Practice Address - Street 1:4436 NW 50TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-2212
Practice Address - Country:US
Practice Address - Phone:405-858-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-06
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator