Provider Demographics
NPI:1194860247
Name:JIM WALLACE AND ASSOCIATES INC.
Entity Type:Organization
Organization Name:JIM WALLACE AND ASSOCIATES INC.
Other - Org Name:THE JETTY COUNSELING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/CEO/PRESIDENT/EXEC. DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:GALE
Authorized Official - Last Name:RUE-WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:MASTERS SCIENCE
Authorized Official - Phone:405-306-8511
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 1:925 15TH AVE NW
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1809
Practice Address - Country:US
Practice Address - Phone:580-224-2830
Practice Address - Fax:405-665-6396
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100749080CMedicaid