Provider Demographics
NPI:1518220110
Name:JONAS, MICHELLE IRENE ANGELIQUE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:IRENE ANGELIQUE
Last Name:JONAS
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 1:1413 N LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-6517
Mailing Address - Country:US
Mailing Address - Phone:405-760-5830
Mailing Address - Fax:
Practice Address - Street 1:1413 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-6517
Practice Address - Country:US
Practice Address - Phone:405-760-5830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK22608104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
22608OtherOKLAHOMA DEPARTMENT OF MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES BHCS LEVEL II