MEDICARE: JORDAN CLAYTON TAYLOR BERRY

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	175T00000X	Peer Specialist		OK

General Provider Information

NPI Number	:	1588516637
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORDAN CLAYTON TAYLOR BERRY

Provider Business Mailing Address
First Line	:	5800 NW 34TH ST APT B22
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73122-1648
Country	:	US
Telephone Number	:	405-235-5671
Fax Number	:

Provider Business Practice Location Address
First Line	:	5800 NW 34TH ST APT B22
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73122-1648
Country	:	US
Telephone Number	:	405-235-5671
Fax Number	:

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

Provider Enumeration Date	:	02/11/2026
Last Update Date	:	02/11/2026

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