MEDICARE: MISS JEANETTE LOUDERMILK M.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	5120	OK
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	5120	OK
3	101Y00000X	Counselor	5120	OK
4	101YP2500X	Professional Counselor	5120	OK
5	106H00000X	Marriage & Family Therapist	5120	OK

General Provider Information

NPI Number	:	1124314588
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS JEANETTE LOUDERMILK M.A.

Provider Business Mailing Address
First Line	:	PO BOX 36434
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73136-2434
Country	:	US
Telephone Number	:	405-818-8489
Fax Number	:

Provider Business Practice Location Address
First Line	:	3816 OAK VALLEY RD
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73135-2055
Country	:	US
Telephone Number	:	405-818-8489
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2011
Last Update Date	:	08/07/2013

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