Provider Demographics
NPI:1699294215
Name:ROUK, KAITLIN JEWEL
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:JEWEL
Last Name:ROUK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3810 HARRELD RD
Mailing Address - Street 2:
Mailing Address - City:BEGGS
Mailing Address - State:OK
Mailing Address - Zip Code:74421-2478
Mailing Address - Country:US
Mailing Address - Phone:918-857-5244
Mailing Address - Fax:
Practice Address - Street 1:1201 W 9TH ST
Practice Address - Street 2:
Practice Address - City:BEGGS
Practice Address - State:OK
Practice Address - Zip Code:74421-2193
Practice Address - Country:US
Practice Address - Phone:918-267-4916
Practice Address - Fax:918-267-4916
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-14
Last Update Date:2017-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health