Healthcare Provider Details

I. General information

NPI: 1215168414
Provider Name (Legal Business Name): JONETTA SUE WAKELY MS, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2009
Last Update Date: 08/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 S.W. PENN
BARTLESVILLE OK
74003-4331
US

IV. Provider business mailing address

700 SW PENN
BARTLESVILLE OK
74003
US

V. Phone/Fax

Practice location:
  • Phone: 918-337-8080
  • Fax: 918-337-8099
Mailing address:
  • Phone: 918-337-8080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4598
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: