Provider Demographics
NPI:1396060448
Name:STEWART, JENNIFER BROOKE (MD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:BROOKE
Last Name:STEWART
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:BROOKE
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4913 W RENO AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73127-6339
Mailing Address - Country:US
Mailing Address - Phone:405-948-4900
Mailing Address - Fax:405-595-3192
Practice Address - Street 1:4913 W RENO AVE
Practice Address - Street 2:OKLAHOMA CITY INDIAN CLINIC
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73127-6339
Practice Address - Country:US
Practice Address - Phone:405-948-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-01
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK29782208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200502840OtherMEDICAID PROVIDER ID