Provider Demographics
NPI:1487818589
Name:ANDERSON, JIM A
Entity Type:Individual
Prefix:
First Name:JIM
Middle Name:A
Last Name:ANDERSON
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 1:4436 NW 50TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-2212
Mailing Address - Country:US
Mailing Address - Phone:405-858-2700
Mailing Address - Fax:
Practice Address - Street 1:2323 W 7TH AVE STE 1
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-1929
Practice Address - Country:US
Practice Address - Phone:405-707-9722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-17
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor