Provider Demographics
NPI:1427391143
Name:JERRELL, SAMANTHA JO
Entity Type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:JO
Last Name:JERRELL
Suffix:
Gender:F
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 832
Mailing Address - Street 2:
Mailing Address - City:MOUNDS
Mailing Address - State:OK
Mailing Address - Zip Code:74047-0832
Mailing Address - Country:US
Mailing Address - Phone:918-693-4638
Mailing Address - Fax:
Practice Address - Street 1:7831 W 182ND ST SOUTH
Practice Address - Street 2:
Practice Address - City:MOUNDS
Practice Address - State:OK
Practice Address - Zip Code:74047
Practice Address - Country:US
Practice Address - Phone:918-693-4638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-01
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health