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NPI Code Detail

MEDICARE: CORY JEANS REVEREND

MEDICARE: CORY JEANS REVEREND
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
1101YP1600XPastoral Counselor
2171M00000XCase Manager/Care Coordinator

General Provider Information

NPI Number : 1396520177
Entity Type Code : Individual
Provider Name (Legal Business Name) : CORY JEANS REVEREND
Provider Business Mailing Address
First Line : 1023 N MILLER DR
Second Line :
City : CLAREMORE
State : OK
Zip : 74017-6622
Country : US
Telephone Number : 918-833-1939
Fax Number :
Provider Business Practice Location Address
First Line : 1219 W DUPONT ST
Second Line :
City : CLAREMORE
State : OK
Zip : 74017-5318
Country : US
Telephone Number : 918-341-9400
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/29/2023
Last Update Date : 08/29/2023

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Directions to “ CORY JEANS REVEREND” Practice Location

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