Provider Demographics
NPI:1255684874
Name:SAMPSON, JANICE KAYE (BHRS)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:KAYE
Last Name:SAMPSON
Suffix:
Gender:F
Credentials:BHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 N AIR DEPOT BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110-1700
Mailing Address - Country:US
Mailing Address - Phone:405-610-6540
Mailing Address - Fax:
Practice Address - Street 1:351 N AIR DEPOT BLVD
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-1700
Practice Address - Country:US
Practice Address - Phone:405-610-6540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-19
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1447559711Medicaid