Provider Demographics
NPI:1922857291
Name:GIRTY, JAELYN NICOLE
Entity type:Individual
Prefix:
First Name:JAELYN
Middle Name:NICOLE
Last Name:GIRTY
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 1:18742 S BUTLER RD
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-1238
Mailing Address - Country:US
Mailing Address - Phone:918-708-5670
Mailing Address - Fax:
Practice Address - Street 1:614 S MAIN ST
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-4059
Practice Address - Country:US
Practice Address - Phone:405-564-3408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-17
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician