Provider Demographics
NPI:1346861796
Name:JANTZ, DELISSA LEANN (BS)
Entity Type:Individual
Prefix:MRS
First Name:DELISSA
Middle Name:LEANN
Last Name:JANTZ
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:DELISSA
Other - Middle Name:LEANN
Other - Last Name:HOFFMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1425 N MAIN ST STE 1
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:OK
Mailing Address - Zip Code:73737-2703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:604 CHOCTAW ST
Practice Address - Street 2:
Practice Address - City:ALVA
Practice Address - State:OK
Practice Address - Zip Code:73717-1626
Practice Address - Country:US
Practice Address - Phone:580-327-1112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-27
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OK11742101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator