Healthcare Provider Details

I. General information

NPI: 1417374299
Provider Name (Legal Business Name): JONETTE KAY PASSMORE CTRS/L, ATRIC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2014
Last Update Date: 03/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3124 W 24TH AVE
STILLWATER OK
74074-2101
US

IV. Provider business mailing address

3124 W 24TH AVE
STILLWATER OK
74074-2101
US

V. Phone/Fax

Practice location:
  • Phone: 405-334-9444
  • Fax:
Mailing address:
  • Phone: 405-334-9444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number54
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: