Provider Demographics
NPI:1558171892
Name:BLACK, JASON T
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:T
Last Name:BLACK
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 1:822 RUSSELL CIR
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-4652
Mailing Address - Country:US
Mailing Address - Phone:405-305-4804
Mailing Address - Fax:
Practice Address - Street 1:900 E MAIN ST
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-5305
Practice Address - Country:US
Practice Address - Phone:405-573-6690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-09
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator