Provider Demographics
NPI:1376757484
Name:BAKER, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:BAKER
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:PO BOX 673
Mailing Address - Street 2:
Mailing Address - City:VALLIANT
Mailing Address - State:OK
Mailing Address - Zip Code:74764-0673
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 N. DALTON AVENUE
Practice Address - Street 2:
Practice Address - City:VALLIANT
Practice Address - State:OK
Practice Address - Zip Code:74764
Practice Address - Country:US
Practice Address - Phone:580-933-7031
Practice Address - Fax:580-933-7034
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor