Provider Demographics
NPI:1477520716
Name:MOON, JODELL LYNN (MED, LPC)
Entity Type:Individual
Prefix:
First Name:JODELL
Middle Name:LYNN
Last Name:MOON
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RED ROCK BHS
Mailing Address - Street 2:112 MCKINLEY STREET
Mailing Address - City:CHANDLER
Mailing Address - State:OK
Mailing Address - Zip Code:74834
Mailing Address - Country:US
Mailing Address - Phone:405-240-5800
Mailing Address - Fax:405-240-5008
Practice Address - Street 1:112 MCKINLEY STREET
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:OK
Practice Address - Zip Code:74834
Practice Address - Country:US
Practice Address - Phone:405-240-5800
Practice Address - Fax:405-240-5008
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1424101YP2500X, 101Y00000X
OK6583101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1477250716Medicaid