Provider Demographics
NPI:1114245305
Name:BLACK, JEANNE DEVO (MED, LPC, LADC)
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:DEVO
Last Name:BLACK
Suffix:
Gender:F
Credentials:MED, LPC, LADC
Other - Prefix:
Other - First Name:JEANNE
Other - Middle Name:DEVO
Other - Last Name:FAIR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED, LPC, LADC
Mailing Address - Street 1:4400 N LINCOLN BLVD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73105-5108
Mailing Address - Country:US
Mailing Address - Phone:405-424-7711
Mailing Address - Fax:
Practice Address - Street 1:4400 N LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73105-5108
Practice Address - Country:US
Practice Address - Phone:405-424-7711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-12
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2534101YP2500X
OK1022101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional