Provider Demographics
NPI:1992095640
Name:WALLENMEYER, JESSICA ANN (MD)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:ANN
Last Name:WALLENMEYER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2109 N KELLY AVE
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003-3908
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2109 N KELLY AVE
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73003-3908
Practice Address - Country:US
Practice Address - Phone:405-513-8880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-14
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP6106208000000X
OK31309208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics