Provider Demographics
NPI:1659720860
Name:SUTTON, JASON NATHANIEL (BS)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:NATHANIEL
Last Name:SUTTON
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:JASON
Other - Middle Name:NATHANIEL
Other - Last Name:BRAGG-SUTTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BS
Mailing Address - Street 1:405 E EXCELSIOR AVE
Mailing Address - Street 2:
Mailing Address - City:VINITA
Mailing Address - State:OK
Mailing Address - Zip Code:74301-4226
Mailing Address - Country:US
Mailing Address - Phone:918-256-6476
Mailing Address - Fax:918-256-3628
Practice Address - Street 1:405 E EXCELSIOR AVE
Practice Address - Street 2:
Practice Address - City:VINITA
Practice Address - State:OK
Practice Address - Zip Code:74301-4226
Practice Address - Country:US
Practice Address - Phone:918-256-6476
Practice Address - Fax:918-256-3628
Is Sole Proprietor?:No
Enumeration Date:2016-06-08
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1659720860Medicaid