| Doctor Name: | MR. JIMMY TODD SELF |
| NPI Number: | 1528171022 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | LPC |
| License Number: | 3651 |
| Business Practice Address: | 32270 E 722 Dr Wagoner, OK - 744677411 |
| Business Phone Number: | 9184859277 |
| Business Fax Number: | |
| Mailing Address: | 32270 E 722 Dr, WAGONER |
| State: | OK |
| Postal Code: | 744677411 |
| Phone Number: | 9184859277 |
| Fax Number: | |
| NPI Enumeration Date: | 08/17/2006 |
| NPI Last Update Date: | 03/30/2009 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YM0800X |
| License Number: | 3651 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | OK |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Mental Health |
| Taxonomy Definition: | |