Provider Demographics
NPI:1265769343
Name:MONK, JACKIE J
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:J
Last Name:MONK
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:RR 1 BOX 181
Mailing Address - Street 2:
Mailing Address - City:GARVIN
Mailing Address - State:OK
Mailing Address - Zip Code:74736-9731
Mailing Address - Country:US
Mailing Address - Phone:580-212-9055
Mailing Address - Fax:580-298-5072
Practice Address - Street 1:608 HIGHWAY 271 N
Practice Address - Street 2:
Practice Address - City:ANTLERS
Practice Address - State:OK
Practice Address - Zip Code:74523-2055
Practice Address - Country:US
Practice Address - Phone:580-298-5062
Practice Address - Fax:580-298-5072
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-10
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor