Provider Demographics
NPI:1831649276
Name:SHAMSOLLAHI, JACKIE LYNN (MS, LPC)
Entity Type:Individual
Prefix:MS
First Name:JACKIE
Middle Name:LYNN
Last Name:SHAMSOLLAHI
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 N 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-4718
Mailing Address - Country:US
Mailing Address - Phone:580-924-6363
Mailing Address - Fax:580-924-0379
Practice Address - Street 1:134 N 12TH AVE
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-4718
Practice Address - Country:US
Practice Address - Phone:580-924-6363
Practice Address - Fax:580-924-0379
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-10
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1853101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health