Provider Demographics
NPI:1821227794
Name:ELISE, JENNIFER B (MS, LBP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:B
Last Name:ELISE
Suffix:
Gender:F
Credentials:MS, LBP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 14354
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73113-0354
Mailing Address - Country:US
Mailing Address - Phone:405-412-9842
Mailing Address - Fax:405-896-9872
Practice Address - Street 1:203 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MADILL
Practice Address - State:OK
Practice Address - Zip Code:73446-2240
Practice Address - Country:US
Practice Address - Phone:405-300-8588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-13
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK321101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional