Provider Demographics
NPI:1851690176
Name:MYRICK, JENNIFER A
Entity Type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:A
Last Name:MYRICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 SW 81ST ST
Mailing Address - Street 2:POX 673 GUTHRIE, OK 73044
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73159-4733
Mailing Address - Country:US
Mailing Address - Phone:405-819-1661
Mailing Address - Fax:
Practice Address - Street 1:2601 SW 81ST ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-4733
Practice Address - Country:US
Practice Address - Phone:495-819-1661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-25
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1003K00000X103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst