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General NPI Number Information
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NPI Number | 1457657165
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Entity Type | Organization
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Legal Business Name | JACK TRACY II, PH.D. PYSCHOLOGICAL SERVICES, PLLC
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Dates
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Enumeration Date | 01/28/2011
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Last Update Date | 02/09/2012
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Provider Practice Location Address
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Address Line | 1006 24TH AVE NW STE 100
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City | NORMAN
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State | OK
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Zip | 73069-6344
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Country | US
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Telephone | 405-801-2836
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Fax |
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Provider Business Mailing Address
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Address Line | 1006 24TH AVE NW STE 100
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City | NORMAN
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State | OK
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Zip | 73069-6344
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Country | US
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Telephone | 405-801-2836
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Fax |
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Authorized Official
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Title or Position | LICENSED PSYCHOLOGIST
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Name | DR. JACK FRANK TRACY II
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Credential | PH.D.
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Telephone | 405-213-6130
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 1120
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License Number State | OK
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