Healthcare Provider Details

I. General information

NPI: 1689177537
Provider Name (Legal Business Name): JEFFREY CHARLES WREN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2018
Last Update Date: 03/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 N LINCOLN BLVD
OKLAHOMA CITY OK
73105-5104
US

IV. Provider business mailing address

5757 W HEFNER RD APT 1301
OKLAHOMA CITY OK
73162-5811
US

V. Phone/Fax

Practice location:
  • Phone: 405-424-7711
  • Fax:
Mailing address:
  • Phone: 405-413-1632
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: