Healthcare Provider Details

I. General information

NPI: 1992405922
Provider Name (Legal Business Name): JOANNA LEE JACKSON LPC-CANDIDATE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2023
Last Update Date: 03/08/2023
Certification Date: 03/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8810 S YALE AVE
TULSA OK
74137-3551
US

IV. Provider business mailing address

8810 S YALE AVE
TULSA OK
74137-3551
US

V. Phone/Fax

Practice location:
  • Phone: 918-760-5243
  • Fax:
Mailing address:
  • Phone: 918-760-5243
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: