=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578865317
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JACKIE FIELDS FOUNDATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2010
-----------------------------------------------------
Last Update Date | 11/30/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2303 PICKENS
-----------------------------------------------------
City | MUSKOGEE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-913-6017
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | POB 1810 2303 PICKENS
-----------------------------------------------------
City | MUSKIGEE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-913-6017
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JACKIE DEVORAH STANFORD
-----------------------------------------------------
Credential | ADM RESIDENTAL CARE
-----------------------------------------------------
Telephone | 918-913-6017
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------