Basic Information
Provider Information
NPI: 1033580014
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: TUGGLE
FirstName: JEAN
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 29 NE 66TH ST
Address2:  
City: OKLAHOMA CITY
State: OK
PostalCode: 731051236
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 29 NE 66TH ST
Address2:  
City: OKLAHOMA CITY
State: OK
PostalCode: 731051236
CountryCode: US
TelephoneNumber: 4058423638
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/15/2015
LastUpdateDate: 10/15/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
171M00000X  Y Other Service ProvidersCase Manager/Care Coordinator 

No ID Information.


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