Provider Demographics
NPI:1780011502
Name:JACK, DAN (MS)
Entity Type:Individual
Prefix:
First Name:DAN
Middle Name:
Last Name:JACK
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11600 SW 4TH ST
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-6706
Mailing Address - Country:US
Mailing Address - Phone:405-229-4348
Mailing Address - Fax:
Practice Address - Street 1:11600 SW 4TH ST
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-6706
Practice Address - Country:US
Practice Address - Phone:405-229-4348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-11
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst