Provider Demographics
NPI:1952632747
Name:GUAJARDO, JENNY LEAH (MED, LPC)
Entity Type:Individual
Prefix:MRS
First Name:JENNY
Middle Name:LEAH
Last Name:GUAJARDO
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 N RANDALL AVE
Mailing Address - Street 2:
Mailing Address - City:ELK CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73644-3345
Mailing Address - Country:US
Mailing Address - Phone:580-243-9218
Mailing Address - Fax:580-303-7977
Practice Address - Street 1:601 N RANDALL AVE
Practice Address - Street 2:
Practice Address - City:ELK CITY
Practice Address - State:OK
Practice Address - Zip Code:73644-3345
Practice Address - Country:US
Practice Address - Phone:580-243-9218
Practice Address - Fax:844-270-5692
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-19
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4536101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200400490AMedicaid