Provider Demographics
NPI:1851869317
Name:PINE, JAIME A (MED BCBA LBA-OK)
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:A
Last Name:PINE
Suffix:
Gender:F
Credentials:MED BCBA LBA-OK
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3903 N HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-1426
Mailing Address - Country:US
Mailing Address - Phone:405-585-2971
Mailing Address - Fax:405-585-2983
Practice Address - Street 1:1960 HARPER ST
Practice Address - Street 2:
Practice Address - City:CHOCTAW
Practice Address - State:OK
Practice Address - Zip Code:73020-8095
Practice Address - Country:US
Practice Address - Phone:405-281-1040
Practice Address - Fax:405-585-2983
Is Sole Proprietor?:No
Enumeration Date:2018-11-02
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK1-19-34407103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200856230AMedicaid