Provider Demographics
NPI:1225152259
Name:ISHCOMER, MARY JACQUE
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:JACQUE
Last Name:ISHCOMER
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:JACQUE
Other - Last Name:ISHCOMER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2000 E LINCOLN RD
Mailing Address - Street 2:
Mailing Address - City:IDABEL
Mailing Address - State:OK
Mailing Address - Zip Code:74745-7353
Mailing Address - Country:US
Mailing Address - Phone:580-286-6639
Mailing Address - Fax:580-286-5206
Practice Address - Street 1:2000 E LINCOLN RD
Practice Address - Street 2:
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745-7353
Practice Address - Country:US
Practice Address - Phone:580-286-6639
Practice Address - Fax:580-286-5206
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health