Healthcare Provider Details

I. General information

NPI: 1144134503
Provider Name (Legal Business Name): JACI MANN BT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

916 N MAIN ST
ALTUS OK
73521-3118
US

IV. Provider business mailing address

22292 E 1590 RD
MOUNTAIN PARK OK
73559-5026
US

V. Phone/Fax

Practice location:
  • Phone: 580-318-9415
  • Fax:
Mailing address:
  • Phone: 580-318-9415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: