Provider Demographics
NPI:1164736278
Name:JACKSON, TRACI BRENEE (MS, LPC CANDIDATE)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:BRENEE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS, LPC CANDIDATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36477 EW 1320
Mailing Address - Street 2:
Mailing Address - City:WEWOKA
Mailing Address - State:OK
Mailing Address - Zip Code:74884-8820
Mailing Address - Country:US
Mailing Address - Phone:580-399-8384
Mailing Address - Fax:
Practice Address - Street 1:300 E. SEMINOLE
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:OK
Practice Address - Zip Code:74858
Practice Address - Country:US
Practice Address - Phone:405-382-2940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-30
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health