Provider Demographics
NPI:1851716989
Name:CARBAJAL, JEANETTE ROSHELLE
Entity Type:Individual
Prefix:MRS
First Name:JEANETTE
Middle Name:ROSHELLE
Last Name:CARBAJAL
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:JEANETTE
Other - Middle Name:ROSHELLE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:427 NE 115TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73114-7669
Mailing Address - Country:US
Mailing Address - Phone:405-824-8577
Mailing Address - Fax:
Practice Address - Street 1:427 NE 115TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73114-7669
Practice Address - Country:US
Practice Address - Phone:405-824-8577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-26
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKU082638764103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst