Provider Demographics
NPI:1649595976
Name:SMITH, JEFF R (RN, MS, MHR)
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:R
Last Name:SMITH
Suffix:
Gender:M
Credentials:RN, MS, MHR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1384 CLASSEN BLVD
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-4653
Mailing Address - Country:US
Mailing Address - Phone:405-412-7183
Mailing Address - Fax:
Practice Address - Street 1:320 12TH AVE NE
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-5238
Practice Address - Country:US
Practice Address - Phone:405-773-3819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-30
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 171M00000X
OK56996163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No163W00000XNursing Service ProvidersRegistered Nurse
No171M00000XOther Service ProvidersCase Manager/Care Coordinator