Healthcare Provider Details

I. General information

NPI: 1407175185
Provider Name (Legal Business Name): JACKIE LEANN HORTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2010
Last Update Date: 08/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RR 4 BOX 854
COALGATE OK
74538-9624
US

IV. Provider business mailing address

RR 4 BOX 854
COALGATE OK
74538-9624
US

V. Phone/Fax

Practice location:
  • Phone: 580-399-5398
  • Fax: 580-927-2346
Mailing address:
  • Phone: 580-399-5398
  • Fax: 580-927-2346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: