MEDICARE: JAHNA BUCKALOO M.S., LPC-U/S

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	101YP2500X	Professional Counselor
2	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1831563378
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAHNA BUCKALOO M.S., LPC-U/S

Provider Business Mailing Address
First Line	:	1300 HOPPE BLVD.
Second Line	:	SUITE 1
City	:	ADA
State	:	OK
Zip	:	74820
Country	:	US
Telephone Number	:	580-436-7211
Fax Number	:	580-272-5757

Provider Business Practice Location Address
First Line	:	1300 HOPPE BLVD STE 4
Second Line	:
City	:	ADA
State	:	OK
Zip	:	74820-2319
Country	:	US
Telephone Number	:	580-272-5170
Fax Number	:

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

Provider Enumeration Date	:	11/20/2015
Last Update Date	:	07/10/2019

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