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General NPI Number Information
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NPI Number | 1265821102
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Entity Type | Individual
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Provider Name | JIMMY SELANDERS JR.
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Gender | Male
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Dates
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Enumeration Date | 01/15/2015
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Last Update Date | 01/15/2015
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Provider Practice Location Address
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Address Line | 32300 S 625 RD
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City | GROVE
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State | OK
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Zip | 74344-6285
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Country | US
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Telephone | 918-786-2930
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Fax | 918-786-5985
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Provider Business Mailing Address
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Address Line | PO BOX 451585
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City | GROVE
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State | OK
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Zip | 74345-1585
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Country | US
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Telephone | 918-786-2930
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Fax | 918-786-5985
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number | 200129910A
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License Number State | OK
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