Basic Information
| Provider Information | |||||||||
| NPI: | 1588332613 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JIM WALLACE & ASSOCIATES, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | THE JETTY COUNSELING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 202 S WASHITA AVE | ||||||||
| Address2: | |||||||||
| City: | WYNNEWOOD | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730987820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056654385 | ||||||||
| FaxNumber: | 4056656396 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 W MAIN ST STE 302 | ||||||||
| Address2: | |||||||||
| City: | ARDMORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 734016322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802242830 | ||||||||
| FaxNumber: | 4056656396 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2021 | ||||||||
| LastUpdateDate: | 09/10/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RUE-WALLACE | ||||||||
| AuthorizedOfficialFirstName: | TERESA | ||||||||
| AuthorizedOfficialMiddleName: | GALE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/CEO/PRESIDENT/EXEC. DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4053068511 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | JIM WALLACE & ASSOCIATES, INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | MASTERS SCIENCE | ||||||||
| NPICertificationDate: | 09/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.