Basic Information
| Provider Information | |||||||||
| NPI: | 1396038055 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | JENA | ||||||||
| MiddleName: | PAIGE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 650 S PEORIA AVE | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741204429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9189916641 | ||||||||
| FaxNumber: | 9185601399 | ||||||||
| Practice Location | |||||||||
| Address1: | 1055 S HOUSTON AVE | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9189213200 | ||||||||
| FaxNumber: | 9185601399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2011 | ||||||||
| LastUpdateDate: | 08/28/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 16800 | TX | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101Y00000X | 6892 | OK | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.