Provider Demographics
NPI:1578756680
Name:LEVERETTE II, JIMMY RYAN
Entity Type:Individual
Prefix:MR
First Name:JIMMY
Middle Name:RYAN
Last Name:LEVERETTE II
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 1:4401 NW 39TH ST APT 316
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-2838
Mailing Address - Country:US
Mailing Address - Phone:405-819-5802
Mailing Address - Fax:
Practice Address - Street 1:1607 PROFESSIONAL CIR
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-6314
Practice Address - Country:US
Practice Address - Phone:405-265-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-22
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health