Provider Demographics
NPI:1528512472
Name:BURTON, JARRELL
Entity type:Individual
Prefix:
First Name:JARRELL
Middle Name:
Last Name:BURTON
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 1:6130 E 32ND ST STE 116
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-5454
Mailing Address - Country:US
Mailing Address - Phone:918-270-2413
Mailing Address - Fax:
Practice Address - Street 1:6130 E 32ND ST STE 116
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-5454
Practice Address - Country:US
Practice Address - Phone:918-270-2413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-09
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK00000000Medicaid