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General NPI Number Information
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NPI Number | 1457142895
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Entity Type | Organization
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Legal Business Name | COUNTRYSIDE PSYCHIATRY, PLLC
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Dates
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Enumeration Date | 05/15/2025
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Last Update Date | 06/13/2025
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Provider Practice Location Address
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Address Line | 411 1/2 N WILSON ST
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City | VINITA
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State | OK
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Zip | 74301
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Country | US
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Telephone | 539-937-1715
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Fax | 539-937-1735
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Provider Business Mailing Address
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Address Line | 411 1/2 N WILSON ST
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City | VINITA
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State | OK
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Zip | 74301
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Country | US
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Telephone | 539-937-1715
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Fax | 539-937-1735
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Authorized Official
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Title or Position | OWNER
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Name | MR. JONATHAN W POOLER
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Credential | APRN-CNP, PMHNP-BC
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Telephone | 539-937-1715
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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