Provider Demographics
NPI:1134491475
Name:JACOX, LESLIE (LPC)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:JACOX
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 N 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-4718
Mailing Address - Country:US
Mailing Address - Phone:580-924-6363
Mailing Address - Fax:580-924-0379
Practice Address - Street 1:134 N 12TH AVE
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-4718
Practice Address - Country:US
Practice Address - Phone:580-924-6363
Practice Address - Fax:580-924-0379
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-02
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2816101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health