Provider Demographics
NPI:1467904680
Name:JARVIS, MARY JORDAN
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JORDAN
Last Name:JARVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:JORDAN
Other - Last Name:RUARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:601 DAY AVE
Mailing Address - Street 2:
Mailing Address - City:LONE WOLF
Mailing Address - State:OK
Mailing Address - Zip Code:73655-9779
Mailing Address - Country:US
Mailing Address - Phone:901-318-8769
Mailing Address - Fax:
Practice Address - Street 1:601 DAY AVE
Practice Address - Street 2:
Practice Address - City:LONE WOLF
Practice Address - State:OK
Practice Address - Zip Code:73655-9779
Practice Address - Country:US
Practice Address - Phone:901-318-8769
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-04
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst