Healthcare Provider Details

I. General information

NPI: 1376971069
Provider Name (Legal Business Name): JORDAN LOVE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2013
Last Update Date: 10/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 S GARNETT RD STE G
TULSA OK
74128-1838
US

IV. Provider business mailing address

2001 S GARNETT RD STE G
TULSA OK
74128-1838
US

V. Phone/Fax

Practice location:
  • Phone: 845-321-2049
  • Fax: 918-516-0397
Mailing address:
  • Phone: 845-321-2049
  • Fax: 918-516-0397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: