Healthcare Provider Details

I. General information

NPI: 1235657842
Provider Name (Legal Business Name): JACQUE S KOMERS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2017
Last Update Date: 09/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6501 N BROADWAY EXT SUITE 180
OKLAHOMA CITY OK
73116
US

IV. Provider business mailing address

25518 N 2850 RD
KINGFISHER OK
73750
US

V. Phone/Fax

Practice location:
  • Phone: 405-607-4041
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: