MEDICARE: JORDAN MYLES HOLMES

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	106H00000X	Marriage & Family Therapist		OK

General Provider Information

NPI Number	:	1447695580
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORDAN MYLES HOLMES

Provider Business Mailing Address
First Line	:	5011 S TOLEDO AVE
Second Line	:	APT 5N
City	:	TULSA
State	:	OK
Zip	:	74135-3309
Country	:	US
Telephone Number	:	618-694-9419
Fax Number	:

Provider Business Practice Location Address
First Line	:	5011 S TOLEDO AVE
Second Line	:	APT 5N
City	:	TULSA
State	:	OK
Zip	:	74135-3309
Country	:	US
Telephone Number	:	618-694-9419
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/02/2013
Last Update Date	:	05/02/2013

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