Basic Information
| Provider Information | |||||||||
| NPI: | 1952677585 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAEZ-JARA | ||||||||
| FirstName: | AMPARO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15022 S XENOPHON AVE | ||||||||
| Address2: | |||||||||
| City: | GLENPOOL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740334329 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1516 S. BOSTON AVENUE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741194029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185616000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2012 | ||||||||
| LastUpdateDate: | 03/28/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.