Provider Demographics
NPI:1457539975
Name:ELLEDGE, JEREMY PAUL (LCSW)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:PAUL
Last Name:ELLEDGE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 MEMPHIS DR
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-2013
Mailing Address - Country:US
Mailing Address - Phone:405-642-9369
Mailing Address - Fax:
Practice Address - Street 1:1120 E MAIN ST
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-5300
Practice Address - Country:US
Practice Address - Phone:405-360-5100
Practice Address - Fax:405-364-3209
Is Sole Proprietor?:No
Enumeration Date:2008-02-06
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK44101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical