MEDICARE: JENNIFER LUCAS BRUSICH PSY.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC2200X	Clinical Child & Adolescent Psychologist	1246	OK

General Provider Information

NPI Number	:	1790157394
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER LUCAS BRUSICH PSY.D.

Provider Business Mailing Address
First Line	:	5212 E 69TH PL
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74136-3407
Country	:	US
Telephone Number	:	918-280-0101
Fax Number	:

Provider Business Practice Location Address
First Line	:	5212 E 69TH PL
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74136-3407
Country	:	US
Telephone Number	:	918-280-0101
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/22/2015
Last Update Date	:	11/21/2019

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