=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598154155
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. JANA SUE LUQUETTE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/20/2015
-----------------------------------------------------
Last Update Date | 04/09/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3915 N PENNSYLVANIA AVE FAMILY RECOVERY COUNSELING CENTER
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73112-7586
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-524-2424
-----------------------------------------------------
Fax | 405-525-3677
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 113 9TH STREET CIR
-----------------------------------------------------
City | CHICKASHA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73018-6813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-351-7430
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------