Provider Demographics
NPI:1245372424
Name:PRUSA, JEFFREY DAVID (MA, LPC, LCPC)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:DAVID
Last Name:PRUSA
Suffix:
Gender:M
Credentials:MA, LPC, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27950 S HIGHWAY 125
Mailing Address - Street 2:UNIT 13-2
Mailing Address - City:MONKEY ISLAND
Mailing Address - State:OK
Mailing Address - Zip Code:74331-3124
Mailing Address - Country:US
Mailing Address - Phone:913-526-8643
Mailing Address - Fax:
Practice Address - Street 1:1520 INDUSTRIAL AVE
Practice Address - Street 2:
Practice Address - City:VINITA
Practice Address - State:OK
Practice Address - Zip Code:74301-4803
Practice Address - Country:US
Practice Address - Phone:918-256-7518
Practice Address - Fax:918-256-6771
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006038837101YP2500X
KS1035101YP2500X
OK4871101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional