Provider Demographics
NPI:1962047183
Name:JENISON, DORETTA (PA-C)
Entity type:Individual
Prefix:
First Name:DORETTA
Middle Name:
Last Name:JENISON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 OAK HILL RD
Mailing Address - Street 2:
Mailing Address - City:CHOCTAW
Mailing Address - State:OK
Mailing Address - Zip Code:73020-7510
Mailing Address - Country:US
Mailing Address - Phone:619-886-0898
Mailing Address - Fax:
Practice Address - Street 1:830 OAK HILL RD
Practice Address - Street 2:
Practice Address - City:CHOCTAW
Practice Address - State:OK
Practice Address - Zip Code:73020-7510
Practice Address - Country:US
Practice Address - Phone:619-886-0898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-12
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant