Provider Demographics
NPI:1609089655
Name:TRACY, JACK FRANK II (PHD)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:FRANK
Last Name:TRACY
Suffix:II
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:405-801-2846
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:405-801-2846
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3829101YM0800X
OK1120103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOKAAA2310Medicare UPIN