Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TR0400X | Rehabilitation Psychologist |
NPI | 1063761252 |
---|---|
Provider Name | Priscilla Jacky |
First Address | Edmond, OK 73003-5827 |
Second Address | Edmond, OK 73003-5827 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/09/2012 |
Last Update Date | 03/09/2012 |