Provider Demographics
NPI:1275852089
Name:GAINES, JENNIFER MICHELE
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:MICHELE
Last Name:GAINES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 590
Mailing Address - Street 2:
Mailing Address - City:HOLDENVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74848-0590
Mailing Address - Country:US
Mailing Address - Phone:405-379-6668
Mailing Address - Fax:
Practice Address - Street 1:117 ROGERS DRIVE
Practice Address - Street 2:
Practice Address - City:HOLDENVILLE
Practice Address - State:OK
Practice Address - Zip Code:74848
Practice Address - Country:US
Practice Address - Phone:405-379-6668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-19
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor