Healthcare Provider Details

I. General information

NPI: 1720912439
Provider Name (Legal Business Name): ONYX HARBOR WELLNESS, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2026
Last Update Date: 06/09/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8008 BEHR DR
EDMOND OK
73034
US

IV. Provider business mailing address

820 W DANFORTH RD UNIT 297
EDMOND OK
73003-5006
US

V. Phone/Fax

Practice location:
  • Phone: 469-728-4404
  • Fax:
Mailing address:
  • Phone: 469-728-4404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: SHAVONDRIA JACOBS
Title or Position: OWNER
Credential: LCSW
Phone: 469-728-4404