Healthcare Provider Details

I. General information

NPI: 1306961479
Provider Name (Legal Business Name): SELENE JAQUEZ BSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 NORTH 31ST STREET
CLINTON OK
73601
US

IV. Provider business mailing address

622 S 6TH ST
CLINTON OK
73601-4616
US

V. Phone/Fax

Practice location:
  • Phone: 580-323-6021
  • Fax: 580-323-9375
Mailing address:
  • Phone: 580-515-0836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: