Healthcare Provider Details

I. General information

NPI: 1366372245
Provider Name (Legal Business Name): JAYSON SERRILL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2026
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25604 HIGHWAY 112
CAMERON OK
74932-2612
US

IV. Provider business mailing address

610 S CHURCH ST
POTEAU OK
74953-3812
US

V. Phone/Fax

Practice location:
  • Phone: 479-357-5140
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number26-533410
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: