Healthcare Provider Details

I. General information

NPI: 1215357660
Provider Name (Legal Business Name): SECOND WIND RECOVERY AND SUPPORT SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2014
Last Update Date: 04/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 N CLASSEN BLVD SUITE C-55
OKLAHOMA CITY OK
73118-2872
US

IV. Provider business mailing address

3700 N CLASSEN BLVD SUITE C-55
OKLAHOMA CITY OK
73118-2872
US

V. Phone/Fax

Practice location:
  • Phone: 405-605-0881
  • Fax: 405-605-0879
Mailing address:
  • Phone: 405-605-0881
  • Fax: 405-605-0879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number490
License Number StateOK

VIII. Authorized Official

Name: MS. JACQUELYN D. JORDAN
Title or Position: CEO/OWNER
Credential: MA, LADC
Phone: 405-605-0881