Provider Demographics
NPI:1861233918
Name:FUNDERBURK, JAKE
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:FUNDERBURK
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 1:1243 S 74TH EAST AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74112-6717
Mailing Address - Country:US
Mailing Address - Phone:318-423-5431
Mailing Address - Fax:
Practice Address - Street 1:1243 S 74TH EAST AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74112-6717
Practice Address - Country:US
Practice Address - Phone:318-423-5431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-03
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKL083484046106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst