Provider Demographics
NPI:1689967556
Name:ST. CLAIR, JESSICCA DIANE (BA)
Entity Type:Individual
Prefix:MISS
First Name:JESSICCA
Middle Name:DIANE
Last Name:ST. CLAIR
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5253
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74702-5253
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1424 W TEXAS ST
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-5752
Practice Address - Country:US
Practice Address - Phone:580-380-5220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-25
Last Update Date:2011-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YM0800X
OKL999552021390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program