Provider Demographics
NPI:1922882323
Name:FISK, JIMMY RAY III
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:RAY
Last Name:FISK
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 NW 42ND ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-6227
Mailing Address - Country:US
Mailing Address - Phone:405-343-0005
Mailing Address - Fax:
Practice Address - Street 1:6051 N BROOKLINE AVE STE 112
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4286
Practice Address - Country:US
Practice Address - Phone:405-810-0054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-24
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK20393-P104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker