Provider Demographics
NPI:1033606702
Name:COUCH, JIM LEE
Entity Type:Individual
Prefix:
First Name:JIM
Middle Name:LEE
Last Name:COUCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2712 SE 94TH ST
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-9153
Mailing Address - Country:US
Mailing Address - Phone:405-412-9461
Mailing Address - Fax:
Practice Address - Street 1:107 N MAIN ST
Practice Address - Street 2:
Practice Address - City:KINGFISHER
Practice Address - State:OK
Practice Address - Zip Code:73750-2730
Practice Address - Country:US
Practice Address - Phone:405-872-6824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-18
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health