Provider Demographics
NPI:1033550520
Name:BURNETT-GREEN, JAYME ELIZABETH (CBHCM II, CPRSS)
Entity Type:Individual
Prefix:
First Name:JAYME
Middle Name:ELIZABETH
Last Name:BURNETT-GREEN
Suffix:
Gender:F
Credentials:CBHCM II, CPRSS
Other - Prefix:
Other - First Name:JAYME
Other - Middle Name:ELIZABETH
Other - Last Name:BURNETT-EVANS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CBHCM II, CPRSS
Mailing Address - Street 1:207 N TAYLOR AVE
Mailing Address - Street 2:
Mailing Address - City:WYNNEWOOD
Mailing Address - State:OK
Mailing Address - Zip Code:73098-4626
Mailing Address - Country:US
Mailing Address - Phone:405-207-0132
Mailing Address - Fax:405-251-5017
Practice Address - Street 1:207 N TAYLOR AVE
Practice Address - Street 2:
Practice Address - City:WYNNEWOOD
Practice Address - State:OK
Practice Address - Zip Code:73098-4626
Practice Address - Country:US
Practice Address - Phone:405-207-0132
Practice Address - Fax:405-251-5017
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-11
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200507080AMedicaid