Healthcare Provider Details

I. General information

NPI: 1023262771
Provider Name (Legal Business Name): JILL MAREE BASHORUN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2008
Last Update Date: 02/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 BIRCH STREET
WELLSTON OK
74881
US

IV. Provider business mailing address

PO BOX 492
WELLSTON OK
74881-0492
US

V. Phone/Fax

Practice location:
  • Phone: 405-356-2533
  • Fax: 405-356-2838
Mailing address:
  • Phone: 405-650-7278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2206
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: