Provider Demographics
NPI:1750649935
Name:INTEGRETED COMPREHENSIVE HEALTH CARE
Entity Type:Organization
Organization Name:INTEGRETED COMPREHENSIVE HEALTH CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CASE MANGER
Authorized Official - Prefix:MR
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:DEJAUN
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-830-1094
Mailing Address - Street 1:4801 N CLASSEN BLVD # 73118
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73118-4627
Mailing Address - Country:US
Mailing Address - Phone:405-843-7300
Mailing Address - Fax:405-843-1306
Practice Address - Street 1:4801 N CLASSEN BLVD # 73118
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73118-4627
Practice Address - Country:US
Practice Address - Phone:405-843-7300
Practice Address - Fax:405-843-1306
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ICHC,LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-04-25
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKSHIZZ10Medicaid