Provider Demographics
NPI:1912678707
Name:WHITE, JODY BLAKE III (BA)
Entity Type:Individual
Prefix:MR
First Name:JODY
Middle Name:BLAKE
Last Name:WHITE
Suffix:III
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8305 S LAKEWOOD PL APT 7
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-2144
Mailing Address - Country:US
Mailing Address - Phone:918-286-9193
Mailing Address - Fax:
Practice Address - Street 1:2323 S HARVARD AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74114-3301
Practice Address - Country:US
Practice Address - Phone:918-293-2140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-22
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator