Provider Demographics
NPI:1700454287
Name:KNOBLOCH, CARLY JESSICA (PMHNP)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:JESSICA
Last Name:KNOBLOCH
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 334
Mailing Address - Street 2:
Mailing Address - City:BIXBY
Mailing Address - State:OK
Mailing Address - Zip Code:74008-0334
Mailing Address - Country:US
Mailing Address - Phone:918-943-3790
Mailing Address - Fax:918-943-3793
Practice Address - Street 1:11911 S MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:BIXBY
Practice Address - State:OK
Practice Address - Zip Code:74008-2030
Practice Address - Country:US
Practice Address - Phone:918-943-3790
Practice Address - Fax:918-943-3793
Is Sole Proprietor?:No
Enumeration Date:2021-06-11
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN1509432084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry