Provider Demographics
NPI:1689686164
Name:GENTRY, JAN C (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JAN
Middle Name:C
Last Name:GENTRY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9322 E 41ST
Mailing Address - Street 2:RM 257
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74145-6106
Mailing Address - Country:US
Mailing Address - Phone:918-628-2708
Mailing Address - Fax:
Practice Address - Street 1:9322 E 41ST ST
Practice Address - Street 2:RM 257
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74145-3721
Practice Address - Country:US
Practice Address - Phone:918-628-2708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK14701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical