Provider Demographics
NPI:1487878518
Name:SPIVEY, JERRY WAYNE
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:WAYNE
Last Name:SPIVEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 N KLEIN AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73106-4616
Mailing Address - Country:US
Mailing Address - Phone:405-204-0139
Mailing Address - Fax:
Practice Address - Street 1:1215 N KLEIN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73106-4616
Practice Address - Country:US
Practice Address - Phone:405-204-0139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver