Provider Demographics
NPI:1245668110
Name:BOX, JADE CHANTELLE (BHRS)
Entity type:Individual
Prefix:
First Name:JADE
Middle Name:CHANTELLE
Last Name:BOX
Suffix:
Gender:F
Credentials:BHRS
Other - Prefix:
Other - First Name:JADE
Other - Middle Name:CHANTELLE
Other - Last Name:STOUT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1140 INDIGO RD
Mailing Address - Street 2:
Mailing Address - City:BROKEN BOW
Mailing Address - State:OK
Mailing Address - Zip Code:74728-5824
Mailing Address - Country:US
Mailing Address - Phone:580-236-5335
Mailing Address - Fax:
Practice Address - Street 1:1140 INDIGO RD
Practice Address - Street 2:
Practice Address - City:BROKEN BOW
Practice Address - State:OK
Practice Address - Zip Code:74728-5824
Practice Address - Country:US
Practice Address - Phone:580-236-5335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-31
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKBHRS171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator