Basic Information
| Provider Information | |||||||||
| NPI: | 1548368988 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATHIS | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | LYNNE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | L.P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13204 S 267TH EAST AVE | ||||||||
| Address2: | |||||||||
| City: | COWETA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744295864 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184868122 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3015 E SKELLY DR | ||||||||
| Address2: | SUITE 390 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741056317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186650208 | ||||||||
| FaxNumber: | 9186650216 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 1876 | OK | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.