Provider Demographics
NPI:1326881624
Name:NEAL, JACE KONNER
Entity type:Individual
Prefix:
First Name:JACE
Middle Name:KONNER
Last Name:NEAL
Suffix:
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 1:14069 RANCH ACRES DR
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-0650
Mailing Address - Country:US
Mailing Address - Phone:580-236-9810
Mailing Address - Fax:
Practice Address - Street 1:1111 W 17TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74107-1886
Practice Address - Country:US
Practice Address - Phone:918-582-1972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-14
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program