Provider Demographics
NPI:1639400484
Name:CLEMONS, JAMES KENNETH (MS LPC)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:KENNETH
Last Name:CLEMONS
Suffix:
Gender:M
Credentials:MS LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2725 NE EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73507-7147
Mailing Address - Country:US
Mailing Address - Phone:580-704-5575
Mailing Address - Fax:580-585-6436
Practice Address - Street 1:2725 NE EUCLID AVE
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73507-7147
Practice Address - Country:US
Practice Address - Phone:580-704-5575
Practice Address - Fax:580-585-6436
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-19
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK425253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100803130 CMedicaid