Provider Demographics
NPI:1790066769
Name:EARLY, JIMMY JR (BA)
Entity Type:Individual
Prefix:MR
First Name:JIMMY
Middle Name:
Last Name:EARLY
Suffix:JR
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 W MEMORIAL RD APT 5204
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1765
Mailing Address - Country:US
Mailing Address - Phone:405-412-0420
Mailing Address - Fax:
Practice Address - Street 1:4801 NW CLASSEN, SUITE #233
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73118
Practice Address - Country:US
Practice Address - Phone:405-242-5031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-06
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health