Provider Demographics
NPI:1811217557
Name:LEDBETTER, JACKIE RENEA
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:RENEA
Last Name:LEDBETTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1222 NW 17TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73106-4202
Mailing Address - Country:US
Mailing Address - Phone:405-525-3963
Mailing Address - Fax:405-525-3963
Practice Address - Street 1:9500 NE 150TH ST
Practice Address - Street 2:
Practice Address - City:JONES
Practice Address - State:OK
Practice Address - Zip Code:73049-8601
Practice Address - Country:US
Practice Address - Phone:405-396-3391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-04
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor