Healthcare Provider Details

I. General information

NPI: 1407905284
Provider Name (Legal Business Name): EDISON DALE JEFFUS JR. PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 12/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3220 S PEORIA AVE SUITE 2
TULSA OK
74105-2003
US

IV. Provider business mailing address

509 W 33RD ST
SAND SPRINGS OK
74063-2934
US

V. Phone/Fax

Practice location:
  • Phone: 918-749-5506
  • Fax: 918-749-5506
Mailing address:
  • Phone: 918-241-1149
  • Fax: 918-749-5506

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number636
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number636
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: