Basic Information
| Provider Information | |||||||||
| NPI: | 1447520135 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACK | ||||||||
| FirstName: | SHELLY | ||||||||
| MiddleName: | DENISE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | BHRS CM II | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MARTIN | ||||||||
| OtherFirstName: | SHELLY | ||||||||
| OtherMiddleName: | DENISE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1185 S OREGON AVE | ||||||||
| Address2: | |||||||||
| City: | ATOKA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 745252879 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802303079 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1088 S GIN RD | ||||||||
| Address2: | |||||||||
| City: | ATOKA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 745257378 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802392071 | ||||||||
| FaxNumber: | 5805095041 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2012 | ||||||||
| LastUpdateDate: | 10/30/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | N | Behavioral Health & Social Service Providers | Social Worker | 261QM0801X | OK | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.