=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215328026
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PAULETTE JOBE LCSW
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2015
-----------------------------------------------------
Last Update Date | 02/16/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5480 MAIN STREET SUITE 104
-----------------------------------------------------
City | DEL CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73115-9998
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-772-7440
-----------------------------------------------------
Fax | 405-601-7796
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5480 MAIN STREET SUITE 104
-----------------------------------------------------
City | DEL CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73115-9998
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-772-7440
-----------------------------------------------------
Fax | 405-601-7796
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MEMBER
-----------------------------------------------------
Name | DAETON PAULETTE JOBE
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 405-772-7440
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 3944
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------