Provider Demographics
NPI:1073135463
Name:MCNALLY, JACQUELINE (RBT)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:MCNALLY
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2524 NW 16TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73107-4840
Mailing Address - Country:US
Mailing Address - Phone:405-831-4045
Mailing Address - Fax:
Practice Address - Street 1:13905 TECHNOLOGY DR
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134-1054
Practice Address - Country:US
Practice Address - Phone:405-831-4045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-08
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKBACB510774106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician