Basic Information
Provider Information | |||||||||
NPI: | 1508204249 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FERGUSON | ||||||||
FirstName: | JEREMY | ||||||||
MiddleName: | DAVID | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MA, LMFT-US | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3015 E SKELLY DR | ||||||||
Address2: | SUITE 103 | ||||||||
City: | TULSA | ||||||||
State: | OK | ||||||||
PostalCode: | 741056317 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9187120859 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3015 E SKELLY DR | ||||||||
Address2: | SUITE 103 | ||||||||
City: | TULSA | ||||||||
State: | OK | ||||||||
PostalCode: | 741056317 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9187120859 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/04/2013 | ||||||||
LastUpdateDate: | 06/30/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 101Y00000X |   |   | Y |   | Behavioral Health & Social Service Providers | Counselor |   |
No ID Information.