Healthcare Provider Details

I. General information

NPI: 1306962766
Provider Name (Legal Business Name): CHERI JAN TIPTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 N KENNEDY AVE
SHAWNEE OK
74801-4700
US

IV. Provider business mailing address

1414 N KENNEDY AVE
SHAWNEE OK
74801-4700
US

V. Phone/Fax

Practice location:
  • Phone: 405-275-3391
  • Fax:
Mailing address:
  • Phone: 405-275-3391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number8530351294
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: