Healthcare Provider Details

I. General information

NPI: 1558047027
Provider Name (Legal Business Name): JARED GROB MA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2023
Last Update Date: 06/27/2023
Certification Date: 06/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13707 FAIRHILL AVE
EDMOND OK
73013-1946
US

IV. Provider business mailing address

13707 FAIRHILL AVE
EDMOND OK
73013-1946
US

V. Phone/Fax

Practice location:
  • Phone: 405-607-4041
  • Fax: 405-463-0090
Mailing address:
  • Phone: 405-607-4041
  • Fax: 405-463-0090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPCCANDIDATE11561
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: