Provider Demographics
NPI:1558722652
Name:CRAIGHEAD, JESSE
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:CRAIGHEAD
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 1:747 HIGHWAY 59 # 4
Mailing Address - Street 2:
Mailing Address - City:WESTVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74965-1508
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:747 HIGHWAY 59 # 4
Practice Address - Street 2:
Practice Address - City:WESTVILLE
Practice Address - State:OK
Practice Address - Zip Code:74965-1508
Practice Address - Country:US
Practice Address - Phone:918-723-3757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-16
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK200534020A101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor