Individual
MR. JACK L. FORTENBERRY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
LMSW
Contact information
Practice address
14625 NE 23RD STREET, CHOCTAW, OK 73020
(405) 390-8131
(405) 390-8134
Mailing address
PO BOX 695, CHOCTAW, OK 73020-0695
(405) 390-8131
(405) 390-8134
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
3030
OK
Other
Enumeration date
01/31/2007
Last updated
07/08/2007
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