Provider Demographics
NPI:1225582661
Name:THIBODEAU, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:THIBODEAU
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 1:200 S HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CUSHING
Mailing Address - State:OK
Mailing Address - Zip Code:74023-4117
Mailing Address - Country:US
Mailing Address - Phone:918-225-5200
Mailing Address - Fax:918-225-0828
Practice Address - Street 1:200 S HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:CUSHING
Practice Address - State:OK
Practice Address - Zip Code:74023-4117
Practice Address - Country:US
Practice Address - Phone:918-225-5200
Practice Address - Fax:918-225-0828
Is Sole Proprietor?:No
Enumeration Date:2016-08-14
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12050183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist