Provider Demographics
NPI:1194094037
Name:PERKINS, JIMMY RAY JR
Entity type:Individual
Prefix:
First Name:JIMMY
Middle Name:RAY
Last Name:PERKINS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2505 MONTA PL
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74403-6032
Mailing Address - Country:US
Mailing Address - Phone:918-231-7425
Mailing Address - Fax:
Practice Address - Street 1:3300 CHANDLER RD STE 109
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74403-4909
Practice Address - Country:US
Practice Address - Phone:918-686-6876
Practice Address - Fax:918-686-6826
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-21
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23714171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator