Provider Demographics
NPI:1275817611
Name:JACK, KRISTI DENISE
Entity Type:Individual
Prefix:MRS
First Name:KRISTI
Middle Name:DENISE
Last Name:JACK
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:KRISTI
Other - Middle Name:DENISE
Other - Last Name:GIPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1185 S OREGON AVE
Mailing Address - Street 2:
Mailing Address - City:ATOKA
Mailing Address - State:OK
Mailing Address - Zip Code:74525-2879
Mailing Address - Country:US
Mailing Address - Phone:580-239-2373
Mailing Address - Fax:
Practice Address - Street 1:1088 S GIN RD
Practice Address - Street 2:
Practice Address - City:ATOKA
Practice Address - State:OK
Practice Address - Zip Code:74525-7378
Practice Address - Country:US
Practice Address - Phone:580-239-2071
Practice Address - Fax:580-509-5041
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-04
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor