Healthcare Provider Details

I. General information

NPI: 1801078621
Provider Name (Legal Business Name): LURA LEA JAQUESS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2007
Last Update Date: 05/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 CEDAR AVE.
BARNSDALL OK
74002
US

IV. Provider business mailing address

609 CEDAR
BARNSDALL OK
74002
US

V. Phone/Fax

Practice location:
  • Phone: 918-637-7443
  • Fax:
Mailing address:
  • Phone: 918-637-7443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: