Healthcare Provider Details

I. General information

NPI: 1245589365
Provider Name (Legal Business Name): JENNIFER ANNE REGESTER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2012
Last Update Date: 04/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1129 S ASPEN AVE
BROKEN ARROW OK
74012-4859
US

IV. Provider business mailing address

1129 S ASPEN AVE
BROKEN ARROW OK
74012-4859
US

V. Phone/Fax

Practice location:
  • Phone: 918-764-9300
  • Fax: 918-764-9275
Mailing address:
  • Phone: 918-764-9300
  • Fax: 918-764-9275

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4832
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: