Healthcare Provider Details

I. General information

NPI: 1528433703
Provider Name (Legal Business Name): JADAN ENOCH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2015
Last Update Date: 12/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900761 S 3550 RD
STROUD OK
74079-3935
US

IV. Provider business mailing address

900761 S 3550 RD
STROUD OK
74079-3935
US

V. Phone/Fax

Practice location:
  • Phone: 918-968-5656
  • Fax:
Mailing address:
  • Phone: 918-968-5656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: