Provider Demographics
NPI:1538434246
Name:MASON, ISACC JERMAYNE
Entity type:Individual
Prefix:MR
First Name:ISACC
Middle Name:JERMAYNE
Last Name:MASON
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 1:15 NW VILLAGE GREEN DR APT 232
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505
Mailing Address - Country:US
Mailing Address - Phone:580-583-8788
Mailing Address - Fax:
Practice Address - Street 1:15 NW VILLAGE GREEN DR APT 232
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-5987
Practice Address - Country:US
Practice Address - Phone:580-583-8788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-13
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKN083011721103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst