Healthcare Provider Details

I. General information

NPI: 1437819018
Provider Name (Legal Business Name): JONATHAN CHARLES DAVIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2021
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 N ELM AVE APT 1007
BROKEN ARROW OK
74012-7979
US

IV. Provider business mailing address

3301 N ELM AVE APT 1007
BROKEN ARROW OK
74012-7979
US

V. Phone/Fax

Practice location:
  • Phone: 405-614-0471
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number114089
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: