Provider Demographics
NPI:1609198647
Name:RICKETTS, DELORSE JEAN
Entity type:Individual
Prefix:
First Name:DELORSE
Middle Name:JEAN
Last Name:RICKETTS
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 1:334754 E TIMBER OAKS DR
Mailing Address - Street 2:
Mailing Address - City:WELLSTON
Mailing Address - State:OK
Mailing Address - Zip Code:74881-8180
Mailing Address - Country:US
Mailing Address - Phone:405-356-2188
Mailing Address - Fax:
Practice Address - Street 1:112 MCKINLEY AVE
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:OK
Practice Address - Zip Code:74834-1622
Practice Address - Country:US
Practice Address - Phone:405-258-3040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-18
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health