Healthcare Provider Details

I. General information

NPI: 1891523825
Provider Name (Legal Business Name): JACQUELINE THOMAS LMSW-P
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2024
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 NW 5TH ST
MOORE OK
73160-3948
US

IV. Provider business mailing address

620 NW 5TH ST
MOORE OK
73160-3948
US

V. Phone/Fax

Practice location:
  • Phone: 405-208-4469
  • Fax: 405-208-4472
Mailing address:
  • Phone: 405-208-4469
  • Fax: 405-208-4472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number22835-P
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: