Healthcare Provider Details

I. General information

NPI: 1225713860
Provider Name (Legal Business Name): JESSIE TIBBS PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2023
Last Update Date: 09/21/2023
Certification Date: 09/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 NE 13TH ST
OKLAHOMA CITY OK
73104-5007
US

IV. Provider business mailing address

921 NE 13TH ST (183)
OKLAHOMA CITY OK
73104-5007
US

V. Phone/Fax

Practice location:
  • Phone: 405-456-1000
  • Fax:
Mailing address:
  • Phone: 405-456-3888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1431
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: