Provider Demographics
NPI:1679717722
Name:MATHIS, JERRI LYNN (MSW, LCSW)
Entity type:Individual
Prefix:MRS
First Name:JERRI
Middle Name:LYNN
Last Name:MATHIS
Suffix:
Gender:F
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 1:15795 OLD MORRIS HWY
Mailing Address - Street 2:
Mailing Address - City:OKMULGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74447-8520
Mailing Address - Country:US
Mailing Address - Phone:917-756-5405
Mailing Address - Fax:918-577-3876
Practice Address - Street 1:1101 HONOR HEIGHTS DR
Practice Address - Street 2:JACK C. MONTGOMERY VA MEDICAL CENTER
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-1302
Practice Address - Country:US
Practice Address - Phone:918-577-3225
Practice Address - Fax:918-756-3876
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-20
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK22411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical