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Oklahoma Board of Medical Licensure and Supervision

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WALLACE, JENNIFER LINDSEY       
This verification service provides current data extracted by the Oklahoma State Board of Medical Licensure and Supervision (OSBMLS) from its own database. The data enclosed in the green box below is provided by and controlled entirely by the OSBMLS and therefore constitutes a primary source verification of licensure status as authentic as a direct inquiry to the OSBMLS. NPI# and hospital privileges (if any) are provided by the licensee and not verified.
Practice Address: MOORE PRIMARY CARE
1400 SE 4TH STREET #H
MOORE OK 73160

Address last updated on 3/30/2012
Phone #: (405) 799-7400
Fax #:
County: CLEVELAND
License: 2113
Dated: 4/1/2012
Expires: 3/31/2013
Temp. Ltr. Issued: 1/3/2012
Temp. Ltr. Expires: 4/1/2012
License Type: Physician Assistant
Specialty:
Status: Inactive
Status Class: Expired License
Restricted to:
CME Year: 0
Pending and/or Past Disciplinary Actions: No Disciplinary Action Taken.
All information below is entered by the licensee but not verified by the Oklahoma Medical Board.
Locations: Hours: Languages:
MOORE PRIMARY CARE
1400 SE 4TH STREET #H
MOORE OK 73160

Phone #: (405) 799-7400
Fax #:

Hospital Privileges:

None listed

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