1376766998 NPI number — JOWANNA S TEAGUE BA,BHRS,CBHCM-D

Table of content: JOWANNA S TEAGUE BA,BHRS,CBHCM-D (NPI 1376766998)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376766998 NPI number — JOWANNA S TEAGUE BA,BHRS,CBHCM-D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TEAGUE
Provider First Name:
JOWANNA
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
BA,BHRS,CBHCM-D
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1376766998
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/13/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
HC 79 BOX 142
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUGO
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74743-9323
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-326-7845
Provider Business Mailing Address Fax Number:
580-298-6699

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 N 5TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUGO
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74743-4005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-326-9475
Provider Business Practice Location Address Fax Number:
580-326-9028
Provider Enumeration Date:
04/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TR0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: LPC07098 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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