Healthcare Provider Details

I. General information

NPI: 1538781406
Provider Name (Legal Business Name): JESSICA WORSHAM RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2020
Last Update Date: 05/13/2020
Certification Date: 05/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1806 24TH AVE NW
NORMAN OK
73069-6392
US

IV. Provider business mailing address

2210 S. SANTE FE AVE. APT 102
MOORE OK
73160
US

V. Phone/Fax

Practice location:
  • Phone: 405-482-1905
  • Fax:
Mailing address:
  • Phone: 209-480-0091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License NumberRBT20117297
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: