Provider Demographics
NPI:1932592714
Name:JACK, MATT PAUL
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:PAUL
Last Name:JACK
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 1:1020 E 43 HWY
Mailing Address - Street 2:
Mailing Address - City:STRINGTOWN
Mailing Address - State:OK
Mailing Address - Zip Code:74569-9006
Mailing Address - Country:US
Mailing Address - Phone:580-239-1004
Mailing Address - Fax:580-889-3887
Practice Address - Street 1:1020 EAST 43 HWY
Practice Address - Street 2:
Practice Address - City:STRINGTOWN
Practice Address - State:OK
Practice Address - Zip Code:74569
Practice Address - Country:US
Practice Address - Phone:580-239-1004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-18
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health