Provider Demographics
NPI:1184154650
Name:MERRICK, JAKE ANTHONY
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:ANTHONY
Last Name:MERRICK
Suffix:
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 1:13220 S 86TH EAST PL
Mailing Address - Street 2:
Mailing Address - City:BIXBY
Mailing Address - State:OK
Mailing Address - Zip Code:74008-3465
Mailing Address - Country:US
Mailing Address - Phone:405-513-0664
Mailing Address - Fax:
Practice Address - Street 1:10441 S REGAL BLVD
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-7188
Practice Address - Country:US
Practice Address - Phone:405-513-0664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-15
Last Update Date:2017-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1034101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral