Provider Demographics
NPI:1326243742
Name:KIRSCH, JACQUELINE F (BA, MHPP,WC,RSS)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:F
Last Name:KIRSCH
Suffix:
Gender:F
Credentials:BA, MHPP,WC,RSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 S MUSKOGEE AVE
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-4717
Mailing Address - Country:US
Mailing Address - Phone:918-207-0078
Mailing Address - Fax:918-207-0558
Practice Address - Street 1:711 S MUSKOGEE AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-4717
Practice Address - Country:US
Practice Address - Phone:918-207-0078
Practice Address - Fax:918-207-0058
Is Sole Proprietor?:No
Enumeration Date:2007-06-16
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1326243742Medicaid
AR116378726Medicaid