Healthcare Provider Details

I. General information

NPI: 1366795015
Provider Name (Legal Business Name): JP SPAVINAW CREEK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2012
Last Update Date: 10/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 CENTER AVE
SPAVINAW OK
74366-0353
US

IV. Provider business mailing address

PO BOX 353 401 CENTER AVENUE
SPAVINAW OK
74366-0353
US

V. Phone/Fax

Practice location:
  • Phone: 918-589-2160
  • Fax:
Mailing address:
  • Phone: 918-589-2160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2502
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0053
License Number StateOK

VIII. Authorized Official

Name: MS. MARGARET AILEEN PLUMMER
Title or Position: MEMBER/PARTNER
Credential: LCSW
Phone: 918-589-2160