=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457937138
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACY D DONNELLY DO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2021
-----------------------------------------------------
Last Update Date | 07/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 512 W ATLANTA ST
-----------------------------------------------------
City | BROKEN ARROW
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74012-7004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-370-4461
-----------------------------------------------------
Fax | 918-512-4723
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5310 E 31ST ST STE LL
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74135-5018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-236-4000
-----------------------------------------------------
Fax | 918-236-4001
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 7721
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------