Healthcare Provider Details

I. General information

NPI: 1316282080
Provider Name (Legal Business Name): JEREMIAH LADRONE WATTS MHR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2012
Last Update Date: 12/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2448 E 81ST STREET SUITE 5125
TULSA OK
74137-4213
US

IV. Provider business mailing address

10829 E 33RD CT
TULSA OK
74146-1804
US

V. Phone/Fax

Practice location:
  • Phone: 918-270-1235
  • Fax: 800-260-7966
Mailing address:
  • Phone: 918-270-1235
  • Fax: 800-260-7966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: