Provider Demographics
NPI:1427624303
Name:TULLY, JACK ARNOLD (DPT)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:ARNOLD
Last Name:TULLY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 NW 6TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73106-7241
Mailing Address - Country:US
Mailing Address - Phone:405-609-3667
Mailing Address - Fax:405-609-3697
Practice Address - Street 1:7005 SE 15TH ST STE 200
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-5126
Practice Address - Country:US
Practice Address - Phone:405-610-2488
Practice Address - Fax:405-610-2484
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-01
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6034225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist