Provider Demographics
NPI:1508178070
Name:BETTY JACKSON COUNSELING SERVICES
Entity Type:Organization
Organization Name:BETTY JACKSON COUNSELING SERVICES
Other - Org Name:BETTY JACKSON COUNSELING SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LIC BEHAVIORAL HEALTH PROFESSIONAL
Authorized Official - Prefix:MS
Authorized Official - First Name:LATIA
Authorized Official - Middle Name:R
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, LADC
Authorized Official - Phone:918-902-5348
Mailing Address - Street 1:200 W HOBSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-3926
Mailing Address - Country:US
Mailing Address - Phone:918-902-5348
Mailing Address - Fax:918-340-5189
Practice Address - Street 1:4528 S SHERIDAN RD STE 117
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74145-1140
Practice Address - Country:US
Practice Address - Phone:918-794-6570
Practice Address - Fax:918-340-5189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-13
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK659101YA0400X
OK3343101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200232480AMedicaid