Active NPI
Kathleen Shepherd Koljack, MD
- Pediatrics Physician
- Jenks, OK
National Provider Identifier
1538112370
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pediatrics Physician
- License
- 15092
- Practice address
- 701 E Main St
Jenks, OK 74037-4316 - Phone
- (918) 298-2264
- Fax
- (918) 298-0923
- NPI assigned
- May 19, 2006
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatrics Physician | 208000000X | 15092 | OK | Primary |
Addresses
Primary practice location
701 E Main St
Jenks, OK 74037-4316
Mailing address
701 E Main St
Jenks, OK 74037-4316
Phone (918) 298-2264
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 100056450D | Medicaid | OK |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1147996800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1398902400000",
"number": "1538112370",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "701 E MAIN ST",
"city": "JENKS",
"state": "OK",
"postal_code": "740374316",
"telephone_number": "918-298-2264",
"fax_number": "918-298-0923"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "701 E MAIN ST",
"city": "JENKS",
"state": "OK",
"postal_code": "740374316",
"telephone_number": "918-298-2264",
"fax_number": "918-298-0923"
}
],
"practiceLocations": [],
"basic": {
"last_name": "KOLJACK",
"first_name": "KATHLEEN",
"middle_name": "SHEPHERD",
"name_prefix": "Dr.",
"credential": "MD",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2006-05-19",
"last_updated": "2014-05-01",
"status": "A"
},
"taxonomies": [
{
"code": "208000000X",
"taxonomy_group": "",
"desc": "Pediatrics",
"state": "OK",
"license": "15092",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "100056450D",
"state": "OK"
}
],
"endpoints": [],
"other_names": []
}Other providers in Jenks, OK
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 1, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.