Provider Demographics
NPI:1992149389
Name:DETRICH, JANE (DO)
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:
Last Name:DETRICH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 W MEMORIAL RD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-8304
Mailing Address - Country:US
Mailing Address - Phone:405-752-3962
Mailing Address - Fax:405-752-3963
Practice Address - Street 1:4300 W MEMORIAL RD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-8304
Practice Address - Country:US
Practice Address - Phone:405-752-3962
Practice Address - Fax:405-752-3963
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-29
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5551208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist