Individual
JORDAN ROBERT REYNOLDS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
1300 HOPPE BLVD STE 6, ADA, OK 74820-2319
(580) 399-7653
Mailing address
512 E 24TH ST, TISHOMINGO, OK 73460-3214
(580) 399-7653
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
—
—
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1548339435
—
OK
Enumeration date
07/26/2011
Last updated
08/25/2024
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