=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003025297
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JIMMIE CHARLES CHASE BS,CADC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 622 SE FRANK PHILLIPS BLVD
-----------------------------------------------------
City | BARTLESVILLE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74003-3917
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-336-4646
-----------------------------------------------------
Fax | 918-336-8710
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 205 S SANTA FE ELGIN
-----------------------------------------------------
City | SEDAN
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67361-8526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-346-2356
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 166
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------