Healthcare Provider Details

I. General information

NPI: 1154647162
Provider Name (Legal Business Name): JACK T STANSELL JR. RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2010
Last Update Date: 04/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 E MAIN ST
NORMAN OK
73071-5305
US

IV. Provider business mailing address

900 E MAIN
NORMAN OK
73069
US

V. Phone/Fax

Practice location:
  • Phone: 405-307-4800
  • Fax:
Mailing address:
  • Phone: 405-307-4800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberR0075432
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: