MEDICARE: JESSICA GRANT

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		OK

General Provider Information

NPI Number	:	1467897850
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA GRANT

Provider Business Mailing Address
First Line	:	312 NE 28TH ST
Second Line	:	SUITE 101
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73105-2804
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	312 NE 28TH ST
Second Line	:	SUITE 101
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73105-2804
Country	:	US
Telephone Number	:	405-231-3150
Fax Number	:

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

Provider Enumeration Date	:	04/30/2013
Last Update Date	:	04/30/2013

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Directions to “ JESSICA GRANT ” Practice Location

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