Organization
JIM WALLACE AND ASSOCIATES INC.
Active
Other names
The Jetty Counseling Center
Organization subpart
No
Provider details
NPI number
Authorized official
MS. TERESA GALE RUE-WALLACE MASTERS SCIENCE (OWNER/CEO/PRESIDENT/EXEC. DIRECTOR)
(405) 306-8511
Entity
Organization
Contact information
Practice address
925 15TH AVE NW, ARDMORE, OK 73401-1809
(580) 224-2830
(405) 665-6396
Mailing address
202 S WASHITA AVE, WYNNEWOOD, OK 73098-7820
(405) 665-4385
(405) 665-6396
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100749080C
—
OK
Enumeration date
02/20/2007
Last updated
09/08/2021
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