Individual
JILL MAREE BASHORUN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LPC
Contact information
Practice address
800 BIRCH STREET, WELLSTON, OK 74881
(405) 356-2533
(405) 356-2838
Mailing address
PO BOX 492, WELLSTON, OK 74881-0492
(405) 650-7278
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
—
—
101YP2500X
Professional Counselor
Primary
2206
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
736081919
—
OK
Enumeration date
11/07/2008
Last updated
02/03/2009
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