Provider Demographics
NPI:1164557492
Name:JIM WALLACE AND ASSOCIATES INCORPORATED
Entity Type:Organization
Organization Name:JIM WALLACE AND ASSOCIATES INCORPORATED
Other - Org Name:THE JETTY COUNSELING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO FINANCIAL ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:E
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-665-4385
Mailing Address - Street 1:202 S WASHITA AVE
Mailing Address - Street 2:
Mailing Address - City:WYNNEWOOD
Mailing Address - State:OK
Mailing Address - Zip Code:73098-7820
Mailing Address - Country:US
Mailing Address - Phone:405-665-4385
Mailing Address - Fax:405-665-6396
Practice Address - Street 1:119 N. BROADWAY
Practice Address - Street 2:SUITE 7
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820
Practice Address - Country:US
Practice Address - Phone:580-310-0860
Practice Address - Fax:405-665-6396
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health