Provider Demographics
NPI:1831287168
Name:MYERS, JACK DOUGLAS (PHD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:DOUGLAS
Last Name:MYERS
Suffix:
Gender:M
Credentials:PHD
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 844
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:OK
Mailing Address - Zip Code:74355-0844
Mailing Address - Country:US
Mailing Address - Phone:918-540-7458
Mailing Address - Fax:
Practice Address - Street 1:207 2ND AVE SW
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354-6818
Practice Address - Country:US
Practice Address - Phone:918-540-7458
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1025103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical