Healthcare Provider Details

I. General information

NPI: 1730394875
Provider Name (Legal Business Name): DR. JACQUELYN MARIE LEBLANC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4502 E 41ST ST SUITE 2H23
TULSA OK
74135-2553
US

IV. Provider business mailing address

5396 E 81ST ST APT 634
TULSA OK
74137-2261
US

V. Phone/Fax

Practice location:
  • Phone: 918-660-3577
  • Fax:
Mailing address:
  • Phone: 918-660-3577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number13907
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: