Basic Information
| Provider Information | |||||||||
| NPI: | 1184228579 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GEORGE | ||||||||
| FirstName: | JAMAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15725 CAPULET DR | ||||||||
| Address2: | |||||||||
| City: | EDMOND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730135059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2149011487 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1737 LINWOOD BLVD | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731065037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052396815 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/25/2020 | ||||||||
| LastUpdateDate: | 11/25/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | U084065323 | 01 | OK | PRIVATE PAY | OTHER |