Healthcare Provider Details

I. General information

NPI: 1821329483
Provider Name (Legal Business Name): JACQUELINE DENISE MYLES MASTER OF SCIENCE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2010
Last Update Date: 01/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4420 N LINCOLN BLVD
OKLAHOMA CITY OK
73105-5104
US

IV. Provider business mailing address

4420 N LINCOLN BLVD
OKLAHOMA CITY OK
73105-5104
US

V. Phone/Fax

Practice location:
  • Phone: 405-525-0452
  • Fax: 405-525-0515
Mailing address:
  • Phone: 405-525-0542
  • Fax: 405-525-0515

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: