Healthcare Provider Details

I. General information

NPI: 1366865545
Provider Name (Legal Business Name): JASON LAMONT DAVIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2014
Last Update Date: 12/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12697 E 51ST ST
TULSA OK
74146-6236
US

IV. Provider business mailing address

12697 E 51ST ST
TULSA OK
74146-6236
US

V. Phone/Fax

Practice location:
  • Phone: 918-505-3259
  • Fax: 918-505-3332
Mailing address:
  • Phone: 918-505-3200
  • Fax: 918-505-3332

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: