Provider Demographics
NPI:1528685401
Name:DEGROAT, JESSICA MICHELLE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MICHELLE
Last Name:DEGROAT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:MICHELLE
Other - Last Name:STEPHENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:205 S PARK LN
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521-5755
Mailing Address - Country:US
Mailing Address - Phone:580-379-6650
Mailing Address - Fax:580-379-6659
Practice Address - Street 1:205 S PARK LN
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-5755
Practice Address - Country:US
Practice Address - Phone:580-379-6650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-26
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS94-10426207Q00000X
OK41596207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine