Individual
JEANETTA BUSSELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
205 W HARTFORD, PONCA CITY, OK 74601
(580) 762-1200
Mailing address
205 W HARTFORD, PONCA CITY, OK 74601
(580) 762-1200
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
10
UNLICENSED NORTHCARE DIRECT CARE SERVICE PROVIDER
OK
Enumeration date
01/15/2010
Last updated
09/18/2012
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