Provider Demographics
NPI:1427317072
Name:DEJACIMO, SONJA (BS)
Entity type:Individual
Prefix:
First Name:SONJA
Middle Name:
Last Name:DEJACIMO
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2623 HARDY SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501-7390
Mailing Address - Country:US
Mailing Address - Phone:918-424-5114
Mailing Address - Fax:
Practice Address - Street 1:111 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-5363
Practice Address - Country:US
Practice Address - Phone:918-423-5204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-16
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK200305190B251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health