Basic Information
| Provider Information | |||||||||
| NPI: | 1972752558 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JENKINS | ||||||||
| FirstName: | LILLIAN | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20211 CEDAR RD | ||||||||
| Address2: | |||||||||
| City: | HENRYETTA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744377284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187332897 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6333 E SKELLY DR | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741356106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187797125 | ||||||||
| FaxNumber: | 9186630203 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2008 | ||||||||
| LastUpdateDate: | 09/18/2008 | ||||||||
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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 | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.