Basic Information
| Provider Information | |||||||||
| NPI: | 1417202912 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAGAN | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | RENAE | ||||||||
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| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7010 S YALE AVE STE 215 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741365743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184922554 | ||||||||
| FaxNumber: | 9184991598 | ||||||||
| Practice Location | |||||||||
| Address1: | 7010 S YALE AVE | ||||||||
| Address2: | STE 215 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184922554 | ||||||||
| FaxNumber: | 9184991598 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2012 | ||||||||
| LastUpdateDate: | 07/20/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.