Provider Demographics
NPI:1407175185
Name:HORTON, JACKIE LEANN
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:LEANN
Last Name:HORTON
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:RR 4 BOX 854
Mailing Address - Street 2:
Mailing Address - City:COALGATE
Mailing Address - State:OK
Mailing Address - Zip Code:74538-9624
Mailing Address - Country:US
Mailing Address - Phone:580-399-5398
Mailing Address - Fax:580-927-2346
Practice Address - Street 1:RR 4 BOX 854
Practice Address - Street 2:
Practice Address - City:COALGATE
Practice Address - State:OK
Practice Address - Zip Code:74538-9624
Practice Address - Country:US
Practice Address - Phone:580-399-5398
Practice Address - Fax:580-927-2346
Is Sole Proprietor?:No
Enumeration Date:2010-05-20
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health