| Doctor Name: | MR. JEFFREY DAVID PRUSA |
| NPI Number: | 1245372424 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | MA, LPC, LCPC |
| License Number: | 2006038837 |
| Business Practice Address: | 1520 Industrial Ave Vinita, OK - 743014803 |
| Business Phone Number: | 9182567518 |
| Business Fax Number: | 9182566771 |
| Mailing Address: | 27950 S Highway 125, Unit 13-2 MONKEY ISLAND |
| State: | OK |
| Postal Code: | 743313124 |
| Phone Number: | 9135268643 |
| Fax Number: | |
| NPI Enumeration Date: | 02/13/2007 |
| NPI Last Update Date: | 09/10/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YP2500X |
| License Number: | 2006038837 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | MO |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Professional |
| Taxonomy Definition: | |