Provider Demographics
NPI:1053145524
Name:DAUGHERTY, JESSICA RENEE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:RENEE
Last Name:DAUGHERTY
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 1:200 MONROE ST APT 21
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-5649
Mailing Address - Country:US
Mailing Address - Phone:918-570-6334
Mailing Address - Fax:
Practice Address - Street 1:200 MONROE ST APT 21
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-5649
Practice Address - Country:US
Practice Address - Phone:918-570-6334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist