Provider Demographics
NPI:1457142895
Name:COUNTRYSIDE PSYCHIATRY, PLLC
Entity type:Organization
Organization Name:COUNTRYSIDE PSYCHIATRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PMHNP
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:POOLER
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:539-937-1715
Mailing Address - Street 1:411 1/2 N WILSON ST
Mailing Address - Street 2:
Mailing Address - City:VINITA
Mailing Address - State:OK
Mailing Address - Zip Code:74301
Mailing Address - Country:US
Mailing Address - Phone:539-937-1715
Mailing Address - Fax:539-937-1735
Practice Address - Street 1:411 1/2 N WILSON ST
Practice Address - Street 2:
Practice Address - City:VINITA
Practice Address - State:OK
Practice Address - Zip Code:74301
Practice Address - Country:US
Practice Address - Phone:539-937-1715
Practice Address - Fax:539-937-1735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-15
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty