Provider Demographics
NPI:1417685538
Name:HEADACHE SPECIALISTS OF OKLAHOMA PLLC
Entity Type:Organization
Organization Name:HEADACHE SPECIALISTS OF OKLAHOMA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JACLYN
Authorized Official - Middle Name:R
Authorized Official - Last Name:DUVALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-697-3138
Mailing Address - Street 1:1516 S YORKTOWN PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4918
Mailing Address - Country:US
Mailing Address - Phone:918-922-8612
Mailing Address - Fax:539-867-2151
Practice Address - Street 1:1516 S YORKTOWN PL
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4918
Practice Address - Country:US
Practice Address - Phone:918-922-8612
Practice Address - Fax:539-867-2151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-09
Last Update Date:2022-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200444390BMedicaid