Healthcare Provider Details

I. General information

NPI: 1629942917
Provider Name (Legal Business Name): JACKALOPE THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2025
Last Update Date: 10/16/2025
Certification Date: 10/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1119 LEAFHURST RD
MOORE OK
73160-8533
US

IV. Provider business mailing address

1119 LEAFHURST RD
MOORE OK
73160-8533
US

V. Phone/Fax

Practice location:
  • Phone: 405-237-5696
  • Fax:
Mailing address:
  • Phone: 405-237-5696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER BLUME
Title or Position: OWNER
Credential: LCSW
Phone: 405-237-5696