Provider Demographics
NPI:1316646672
Name:POAHWAY, JESSIE LOU
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:LOU
Last Name:POAHWAY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1332 N THOMAS ST APT 14
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521-2852
Mailing Address - Country:US
Mailing Address - Phone:580-318-0654
Mailing Address - Fax:
Practice Address - Street 1:615 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-3111
Practice Address - Country:US
Practice Address - Phone:580-471-1855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-27
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator