Provider Demographics
NPI:1447695580
Name:HOLMES, JORDAN MYLES
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:MYLES
Last Name:HOLMES
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 1:5011 S TOLEDO AVE
Mailing Address - Street 2:APT 5N
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-3309
Mailing Address - Country:US
Mailing Address - Phone:618-694-9419
Mailing Address - Fax:
Practice Address - Street 1:5011 S TOLEDO AVE
Practice Address - Street 2:APT 5N
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-3309
Practice Address - Country:US
Practice Address - Phone:618-694-9419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-02
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist