Healthcare Provider Details

I. General information

NPI: 1396038055
Provider Name (Legal Business Name): JENA PAIGE MOORE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2011
Last Update Date: 08/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 S HOUSTON AVE
TULSA OK
74127
US

IV. Provider business mailing address

650 S PEORIA AVE
TULSA OK
74120-4429
US

V. Phone/Fax

Practice location:
  • Phone: 918-921-3200
  • Fax: 918-560-1399
Mailing address:
  • Phone: 918-991-6641
  • Fax: 918-560-1399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6892
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number16800
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: