Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP1600X | Pastoral Counselor | 1034 | OK |
NPI | 1184154650 |
---|---|
Provider Name | Jake Anthony Merrick |
First Address | Bixby, OK 74008-3465 |
Second Address | Tulsa, OK 74133-7188 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/06/2017 |
Last Update Date | 15/06/2017 |