Healthcare Provider Details

I. General information

NPI: 1194544221
Provider Name (Legal Business Name): JACEY-LYNN KATHLEEN BENSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2024
Last Update Date: 03/10/2026
Certification Date: 03/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4908 S SHERIDAN RD
TULSA OK
74145-5712
US

IV. Provider business mailing address

5310 E 31ST ST
TULSA OK
74135-5012
US

V. Phone/Fax

Practice location:
  • Phone: 918-984-9153
  • Fax:
Mailing address:
  • Phone: 918-600-3354
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: