Healthcare Provider Details

I. General information

NPI: 1245111863
Provider Name (Legal Business Name): JESSICA J COURTNEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2025
Last Update Date: 09/10/2025
Certification Date: 09/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

618 E CANADIAN AVE
VINITA OK
74301-3810
US

IV. Provider business mailing address

589 ELKINS LK
HUNTSVILLE TX
77340-7314
US

V. Phone/Fax

Practice location:
  • Phone: 918-256-3424
  • Fax:
Mailing address:
  • Phone: 936-229-7942
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: