Basic Information
| Provider Information | |||||||||
| NPI: | 1164924833 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CALLAWAY | ||||||||
| FirstName: | JENNIFFER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6216 S LEWIS AVE STE 180 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741361077 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 6216 S LEWIS AVE STE 180 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741361077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9189607852 | ||||||||
| FaxNumber: | 5396645738 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2018 | ||||||||
| LastUpdateDate: | 03/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 101YP2500X | 7281 | OK | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.