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General NPI Number Information
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NPI Number | 1164736278
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Entity Type | Individual
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Provider Name | TRACI BRENEE JACKSON MS, LPC CANDIDATE
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Gender | Female
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Dates
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Enumeration Date | 07/30/2010
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Last Update Date | 01/19/2011
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Provider Practice Location Address
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Address Line | 300 E. SEMINOLE
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City | SEMINOLE
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State | OK
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Zip | 74858
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Country | US
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Telephone | 405-382-2940
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Fax |
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Provider Business Mailing Address
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Address Line | 36477 EW 1320
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City | WEWOKA
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State | OK
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Zip | 74884-8820
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Country | US
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Telephone | 580-399-8384
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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