Provider Demographics
NPI:1760418693
Name:CHAMBLISS, JACQUELINE SUE (LCSW)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:SUE
Last Name:CHAMBLISS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10159 E. 11TH
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74128
Mailing Address - Country:US
Mailing Address - Phone:918-835-5033
Mailing Address - Fax:918-835-5760
Practice Address - Street 1:10159 E 11TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74128-3058
Practice Address - Country:US
Practice Address - Phone:918-835-5033
Practice Address - Fax:918-835-5760
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK27181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical