1245372424 NPI number — MR. JEFFREY DAVID PRUSA MA, LPC, LCPC

Table of content: MR. JEFFREY DAVID PRUSA MA, LPC, LCPC (NPI 1245372424)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245372424 NPI number — MR. JEFFREY DAVID PRUSA MA, LPC, LCPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRUSA
Provider First Name:
JEFFREY
Provider Middle Name:
DAVID
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MA, LPC, LCPC
Provider Gender Code:
M

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:
1245372424
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
27950 S HIGHWAY 125
Provider Second Line Business Mailing Address:
UNIT 13-2
Provider Business Mailing Address City Name:
MONKEY ISLAND
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74331-3124
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-526-8643
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1520 INDUSTRIAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VINITA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74301-4803
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-256-7518
Provider Business Practice Location Address Fax Number:
918-256-6771
Provider Enumeration Date:
02/13/2007

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: 101YP2500X , with the licence number:  2006038837 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: 1035 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: 4871 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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