Provider Demographics
NPI:1821646654
Name:HODGDEN, JACK LAWRENCE (MS, LPC CANIDATE)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:LAWRENCE
Last Name:HODGDEN
Suffix:
Gender:M
Credentials:MS, LPC CANIDATE
Other - Prefix:
Other - First Name:JACK
Other - Middle Name:LAWRENCE
Other - Last Name:HODGDEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, LPC CANIDATE
Mailing Address - Street 1:5205 GRIZZLY LN
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73703-5069
Mailing Address - Country:US
Mailing Address - Phone:580-402-5332
Mailing Address - Fax:
Practice Address - Street 1:605 W OXFORD AVE
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-1208
Practice Address - Country:US
Practice Address - Phone:580-233-7220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-26
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
OK101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor