Provider Demographics
NPI:1659602159
Name:FRY, JEFFREY DON (BHRS)
Entity Type:Individual
Prefix:MISS
First Name:JEFFREY
Middle Name:DON
Last Name:FRY
Suffix:
Gender:M
Credentials:BHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11730 W HIGHWAY 9
Mailing Address - Street 2:
Mailing Address - City:STIGLER
Mailing Address - State:OK
Mailing Address - Zip Code:74462-2468
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11730 W HIGHWAY 9
Practice Address - Street 2:
Practice Address - City:STIGLER
Practice Address - State:OK
Practice Address - Zip Code:74462-2468
Practice Address - Country:US
Practice Address - Phone:918-635-5158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-22
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100746580AMedicaid