Provider Demographics
NPI:1720349327
Name:PRUITT, JENNIE
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:
Last Name:PRUITT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:747 HIGHWAY 59 STE 4
Mailing Address - Street 2:
Mailing Address - City:WESTVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74965-1508
Mailing Address - Country:US
Mailing Address - Phone:479-220-9857
Mailing Address - Fax:
Practice Address - Street 1:747 HIGHWAY 59 STE 4
Practice Address - Street 2:
Practice Address - City:WESTVILLE
Practice Address - State:OK
Practice Address - Zip Code:74965
Practice Address - Country:US
Practice Address - Phone:479-220-9857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-31
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor