Provider Demographics
NPI:1861768715
Name:JACK, MICKEY DEWAYNE (BHRS)
Entity type:Individual
Prefix:MR
First Name:MICKEY
Middle Name:DEWAYNE
Last Name:JACK
Suffix:
Gender:M
Credentials:BHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:ATOKA
Mailing Address - State:OK
Mailing Address - Zip Code:74525-2501
Mailing Address - Country:US
Mailing Address - Phone:580-230-1613
Mailing Address - Fax:
Practice Address - Street 1:303 E COURT ST
Practice Address - Street 2:
Practice Address - City:ATOKA
Practice Address - State:OK
Practice Address - Zip Code:74525-2047
Practice Address - Country:US
Practice Address - Phone:580-889-3399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-26
Last Update Date:2012-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health