Provider Demographics
NPI:1396360640
Name:PRESLEY, JORDAN MARQUETT I
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:MARQUETT
Last Name:PRESLEY
Suffix:I
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 1:3036 S 214TH ST W
Mailing Address - Street 2:
Mailing Address - City:BOYNTON
Mailing Address - State:OK
Mailing Address - Zip Code:74422-5103
Mailing Address - Country:US
Mailing Address - Phone:539-286-9624
Mailing Address - Fax:
Practice Address - Street 1:109 S HARRILL AVE
Practice Address - Street 2:
Practice Address - City:WAGONER
Practice Address - State:OK
Practice Address - Zip Code:74467-5317
Practice Address - Country:US
Practice Address - Phone:918-485-0242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-12
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
OK101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor