Provider Demographics
NPI:1972105138
Name:IRELAND, JANE ANN
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:ANN
Last Name:IRELAND
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 1:1101 E PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-1744
Mailing Address - Country:US
Mailing Address - Phone:580-765-0152
Mailing Address - Fax:
Practice Address - Street 1:1101 E PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-1744
Practice Address - Country:US
Practice Address - Phone:580-765-0152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-12
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8761183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist