Provider Demographics
NPI:1972168359
Name:ANDERSON, JO ANN JODY
Entity Type:Individual
Prefix:
First Name:JO ANN
Middle Name:JODY
Last Name:ANDERSON
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 1:3131 S MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-2035
Mailing Address - Country:US
Mailing Address - Phone:918-381-0580
Mailing Address - Fax:
Practice Address - Street 1:3010 S HARVARD AVE STE 110
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74114-6126
Practice Address - Country:US
Practice Address - Phone:918-749-1840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-01
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2768101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor