Provider Demographics
NPI:1578865317
Name:JACKIE FIELDS FOUNDATION
Entity type:Organization
Organization Name:JACKIE FIELDS FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:DEVORAH
Authorized Official - Last Name:STANFORD
Authorized Official - Suffix:
Authorized Official - Credentials:ADM RESIDENTAL CARE
Authorized Official - Phone:918-913-6017
Mailing Address - Street 1:POB 1810 2303 PICKENS
Mailing Address - Street 2:
Mailing Address - City:MUSKIGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74402
Mailing Address - Country:US
Mailing Address - Phone:918-913-6017
Mailing Address - Fax:
Practice Address - Street 1:2303 PICKENS
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74402
Practice Address - Country:US
Practice Address - Phone:918-913-6017
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-30
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities