Provider Demographics
NPI:1679754113
Name:JACK D NORRELL, LCSW
Entity Type:Organization
Organization Name:JACK D NORRELL, LCSW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:RONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:NORRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-536-3900
Mailing Address - Street 1:6205 W GORE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-5836
Mailing Address - Country:US
Mailing Address - Phone:580-536-3900
Mailing Address - Fax:580-357-8787
Practice Address - Street 1:6205 W GORE BLVD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-5836
Practice Address - Country:US
Practice Address - Phone:580-536-3900
Practice Address - Fax:580-357-8787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-26
Last Update Date:2009-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2313101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK248305404Medicare PIN