Healthcare Provider Details

I. General information

NPI: 1184154650
Provider Name (Legal Business Name): JAKE ANTHONY MERRICK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2017
Last Update Date: 06/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10441 S REGAL BLVD
TULSA OK
74133-7188
US

IV. Provider business mailing address

13220 S 86TH EAST PL
BIXBY OK
74008-3465
US

V. Phone/Fax

Practice location:
  • Phone: 405-513-0664
  • Fax:
Mailing address:
  • Phone: 405-513-0664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number1034
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: