Provider Demographics
NPI:1316283245
Name:TRAMMELL, JIM LEE (MS)
Entity type:Individual
Prefix:MR
First Name:JIM
Middle Name:LEE
Last Name:TRAMMELL
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:113 W SHAWNEE ST
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-3623
Mailing Address - Country:US
Mailing Address - Phone:918-825-1405
Mailing Address - Fax:918-825-1406
Practice Address - Street 1:113 W. SHAWNEE ST
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464
Practice Address - Country:US
Practice Address - Phone:918-825-1405
Practice Address - Fax:918-825-1406
Is Sole Proprietor?:No
Enumeration Date:2012-12-20
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200046400AMedicaid