Provider Demographics
NPI:1083058697
Name:STAFFORD, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 N YORK ST
Mailing Address - Street 2:SUITE G
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74403-1404
Mailing Address - Country:US
Mailing Address - Phone:918-682-9292
Mailing Address - Fax:918-682-0054
Practice Address - Street 1:1805 N YORK ST
Practice Address - Street 2:SUITE G
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74403-1404
Practice Address - Country:US
Practice Address - Phone:918-682-9292
Practice Address - Fax:918-682-0054
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-25
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health