1194860247 NPI number — JIM WALLACE AND ASSOCIATES INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194860247 NPI number — JIM WALLACE AND ASSOCIATES INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JIM WALLACE AND ASSOCIATES INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
THE JETTY COUNSELING CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194860247
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/08/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
202 S WASHITA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WYNNEWOOD
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73098-7820
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-665-4385
Provider Business Mailing Address Fax Number:
405-665-6396

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
925 15TH AVE NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARDMORE
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73401-1809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-224-2830
Provider Business Practice Location Address Fax Number:
405-665-6396
Provider Enumeration Date:
02/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RUE-WALLACE
Authorized Official First Name:
TERESA
Authorized Official Middle Name:
GALE
Authorized Official Title or Position:
OWNER/CEO/PRESIDENT/EXEC. DIRECTOR
Authorized Official Telephone Number:
405-306-8511

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100749080C , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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