Provider Demographics
NPI:1669639720
Name:BRIDGFORTH, JENIECE ANN (CADC UNDERSUPERVISIO)
Entity Type:Individual
Prefix:MISS
First Name:JENIECE
Middle Name:ANN
Last Name:BRIDGFORTH
Suffix:
Gender:F
Credentials:CADC UNDERSUPERVISIO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 N OKLAHOMA AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73105-2724
Mailing Address - Country:US
Mailing Address - Phone:405-528-8686
Mailing Address - Fax:405-528-8692
Practice Address - Street 1:2701 N OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73105-2724
Practice Address - Country:US
Practice Address - Phone:405-528-8686
Practice Address - Fax:405-528-8692
Is Sole Proprietor?:No
Enumeration Date:2008-05-16
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100742400FMedicaid
OK100742400 BMedicaid