MEDICARE: JAN MATHESON COUNSELING

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	1185	OK

General Provider Information

NPI Number	:	1255798914
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JAN MATHESON COUNSELING

Provider Business Mailing Address
First Line	:	1918 LAKE RD
Second Line	:
City	:	PONCA CITY
State	:	OK
Zip	:	74604-4800
Country	:	US
Telephone Number	:	580-765-2581
Fax Number	:

Provider Business Practice Location Address
First Line	:	1918 LAKE RD
Second Line	:
City	:	PONCA CITY
State	:	OK
Zip	:	74604-4800
Country	:	US
Telephone Number	:	580-765-2581
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JANET MARIE MATHESON
Credential	:	LPC
Telephone Number	:	580-765-2639

Provider Enumeration Date	:	01/25/2016
Last Update Date	:	01/25/2016

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