Provider Demographics
NPI:1235743188
Name:WALES, JONATHAN CARL (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:CARL
Last Name:WALES
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 177
Mailing Address - Street 2:
Mailing Address - City:SEILING
Mailing Address - State:OK
Mailing Address - Zip Code:73663-0177
Mailing Address - Country:US
Mailing Address - Phone:580-922-5656
Mailing Address - Fax:580-922-3261
Practice Address - Street 1:1116 19TH ST
Practice Address - Street 2:
Practice Address - City:WOODWARD
Practice Address - State:OK
Practice Address - Zip Code:73801-2925
Practice Address - Country:US
Practice Address - Phone:580-922-5656
Practice Address - Fax:580-922-3261
Is Sole Proprietor?:No
Enumeration Date:2020-09-08
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK203631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical