Provider Demographics
NPI:1578643946
Name:KRAGH, JEFFREY R
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:R
Last Name:KRAGH
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 1:4045 NW 64TH ST
Mailing Address - Street 2:520
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116-1684
Mailing Address - Country:US
Mailing Address - Phone:405-842-4911
Mailing Address - Fax:
Practice Address - Street 1:4045 NW 64TH ST
Practice Address - Street 2:SUITE 520
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-1684
Practice Address - Country:US
Practice Address - Phone:405-842-4911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK859103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK244535701Medicare ID - Type Unspecified