Provider Demographics
NPI:1023215563
Name:SHORES, JESSICA LEA (MSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEA
Last Name:SHORES
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 E 12TH ST
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-6501
Mailing Address - Country:US
Mailing Address - Phone:580-436-2690
Mailing Address - Fax:
Practice Address - Street 1:111 E 12TH ST
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-6501
Practice Address - Country:US
Practice Address - Phone:580-436-2690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-28
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK10OtherMENTAL HEALTH