Basic Information
| Provider Information | |||||||||
| NPI: | 1366876708 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JEFFCOAT | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | DIANNE | ||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3015 E SKELLY DR | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741056317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187120859 | ||||||||
| FaxNumber: | 9183889708 | ||||||||
| Practice Location | |||||||||
| Address1: | 3015 E SKELLY DR | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741056317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187120859 | ||||||||
| FaxNumber: | 9183889708 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2013 | ||||||||
| LastUpdateDate: | 08/21/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | OK | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 100746170U | 05 | OK | MEDICAID | 100746170G | 05 | OK | MEDICAID |