Provider Demographics
NPI:1124247697
Name:MANGRUM, JANINE LINDA (MS, LADC)
Entity type:Individual
Prefix:
First Name:JANINE
Middle Name:LINDA
Last Name:MANGRUM
Suffix:
Gender:F
Credentials:MS, LADC
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 115
Mailing Address - Street 2:
Mailing Address - City:SAVANNA
Mailing Address - State:OK
Mailing Address - Zip Code:74565-0115
Mailing Address - Country:US
Mailing Address - Phone:918-548-3326
Mailing Address - Fax:
Practice Address - Street 1:1210 N WEST ST
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-2306
Practice Address - Country:US
Practice Address - Phone:918-421-3323
Practice Address - Fax:918-426-0004
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK175101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)