Healthcare Provider Details

I. General information

NPI: 1568650463
Provider Name (Legal Business Name): CANDACE RAE JEFFRIES NICHOLS MS LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CANDACE RAE JEFFRIES LPC

II. Dates (important events)

Enumeration Date: 10/05/2007
Last Update Date: 11/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1108 N WHEELER AVE
SALLISAW OK
74955-2227
US

IV. Provider business mailing address

1108 N WHEELER AVE
SALLISAW OK
74955
US

V. Phone/Fax

Practice location:
  • Phone: 918-775-5513
  • Fax:
Mailing address:
  • Phone: 918-775-5513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4595
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: