Provider Demographics
NPI:1477009090
Name:OKLAHOMA STATE DEPTARTMENT OF HEALTH
Entity Type:Organization
Organization Name:OKLAHOMA STATE DEPTARTMENT OF HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:LEA
Authorized Official - Last Name:BOLAY
Authorized Official - Suffix:
Authorized Official - Credentials:MS,CCC-SLP
Authorized Official - Phone:580-216-4321
Mailing Address - Street 1:804 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:OK
Mailing Address - Zip Code:73077-4230
Mailing Address - Country:US
Mailing Address - Phone:580-216-4321
Mailing Address - Fax:
Practice Address - Street 1:804 N. 7TH ST
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:OK
Practice Address - Zip Code:73077
Practice Address - Country:US
Practice Address - Phone:580-216-4321
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4013251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare