Healthcare Provider Details

I. General information

NPI: 1497362305
Provider Name (Legal Business Name): JTM PIVOT CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2020
Last Update Date: 09/27/2020
Certification Date: 09/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 W 18TH ST STE 100
EDMOND OK
73013-3759
US

IV. Provider business mailing address

1708 NW 39TH ST
OKLAHOMA CITY OK
73118-2608
US

V. Phone/Fax

Practice location:
  • Phone: 405-315-8180
  • Fax: 405-216-5724
Mailing address:
  • Phone: 405-315-8180
  • Fax: 405-216-5724

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JERRY T MCLAUGHLIN
Title or Position: PRESIDENT
Credential: PA-C
Phone: 405-315-8180