Provider Demographics
NPI:1396520177
Name:JEANS, CORY (REVEREND)
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:
Last Name:JEANS
Suffix:
Gender:M
Credentials:REVEREND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1023 N MILLER DR
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74017-6622
Mailing Address - Country:US
Mailing Address - Phone:918-833-1939
Mailing Address - Fax:
Practice Address - Street 1:1219 W DUPONT ST
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-5318
Practice Address - Country:US
Practice Address - Phone:918-341-9400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-29
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral