Provider Demographics
NPI:1457185605
Name:CHILDERS, JESSE COLE
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:COLE
Last Name:CHILDERS
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:PO BOX 721703
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73172-1703
Mailing Address - Country:US
Mailing Address - Phone:405-361-9029
Mailing Address - Fax:
Practice Address - Street 1:8612 NW 125TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73142-2268
Practice Address - Country:US
Practice Address - Phone:405-361-9029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-29
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator