Provider Demographics
NPI:1457657165
Name:JACK TRACY II, PH.D. PYSCHOLOGICAL SERVICES, PLLC
Entity Type:Organization
Organization Name:JACK TRACY II, PH.D. PYSCHOLOGICAL SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:FRANK
Authorized Official - Last Name:TRACY
Authorized Official - Suffix:II
Authorized Official - Credentials:PHD
Authorized Official - Phone:405-213-6130
Mailing Address - Street 1:1006 24TH AVE NW STE 100
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-6344
Mailing Address - Country:US
Mailing Address - Phone:405-801-2836
Mailing Address - Fax:
Practice Address - Street 1:1006 24TH AVE NW STE 100
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-6344
Practice Address - Country:US
Practice Address - Phone:405-801-2836
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-28
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1120103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOKAAA2311Medicare UPIN