Provider Demographics
NPI:1710239181
Name:LAFOUNTAIN, JACK ALLEN (RN)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:ALLEN
Last Name:LAFOUNTAIN
Suffix:
Gender:M
Credentials:RN
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 492
Mailing Address - Street 2:
Mailing Address - City:TIPTON
Mailing Address - State:OK
Mailing Address - Zip Code:73570-0492
Mailing Address - Country:US
Mailing Address - Phone:580-451-0202
Mailing Address - Fax:
Practice Address - Street 1:12033 AGENCY RD
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:AZ
Practice Address - Zip Code:85344-7718
Practice Address - Country:US
Practice Address - Phone:580-451-0202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-10
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK00580163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse