Healthcare Provider Details

I. General information

NPI: 1669885687
Provider Name (Legal Business Name): JACK SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2014
Last Update Date: 03/02/2023
Certification Date: 03/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

933 SW 3RD ST
MOORE OK
73160-2261
US

IV. Provider business mailing address

933 SW 3RD ST
MOORE OK
73160-2261
US

V. Phone/Fax

Practice location:
  • Phone: 405-822-1424
  • Fax:
Mailing address:
  • Phone: 405-822-1424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC07653
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: