Provider Demographics
NPI:1033404876
Name:EDMONDSON, JENNIFER ERIN (LPC, LADC, CMIII)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ERIN
Last Name:EDMONDSON
Suffix:
Gender:F
Credentials:LPC, LADC, CMIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 S STATE ST STE 100
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-3507
Mailing Address - Country:US
Mailing Address - Phone:405-315-7093
Mailing Address - Fax:
Practice Address - Street 1:1601 S STATE ST STE 100
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-3507
Practice Address - Country:US
Practice Address - Phone:405-315-7093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-09
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1067101YA0400X
103K00000X
OK5028101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200370610BMedicaid