Provider Demographics
NPI:1184437337
Name:LIEDTKE, JADEN THAI ALEXANDRIA (RBT)
Entity type:Individual
Prefix:
First Name:JADEN
Middle Name:THAI ALEXANDRIA
Last Name:LIEDTKE
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6929 S SOONER RD APT 36201
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73135-2724
Mailing Address - Country:US
Mailing Address - Phone:903-399-9688
Mailing Address - Fax:
Practice Address - Street 1:2219 SW 74TH ST STE 109-115
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-3931
Practice Address - Country:US
Practice Address - Phone:405-355-3239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-30
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-24-335086106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician