Healthcare Provider Details

I. General information

NPI: 1932592714
Provider Name (Legal Business Name): MATT PAUL JACK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2015
Last Update Date: 03/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 EAST 43 HWY
STRINGTOWN OK
74569
US

IV. Provider business mailing address

1020 E 43 HWY
STRINGTOWN OK
74569-9006
US

V. Phone/Fax

Practice location:
  • Phone: 580-239-1004
  • Fax:
Mailing address:
  • Phone: 580-239-1004
  • Fax: 580-889-3887

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: