Provider Demographics
NPI:1497026470
Name:REYNOLDS, JANA KATHLEEN (LMSW-P)
Entity type:Individual
Prefix:
First Name:JANA
Middle Name:KATHLEEN
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:LMSW-P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 NW 4TH ST
Mailing Address - Street 2:
Mailing Address - City:STIGLER
Mailing Address - State:OK
Mailing Address - Zip Code:74462-1652
Mailing Address - Country:US
Mailing Address - Phone:918-630-6842
Mailing Address - Fax:918-967-8203
Practice Address - Street 1:905 NW 4TH ST
Practice Address - Street 2:
Practice Address - City:STIGLER
Practice Address - State:OK
Practice Address - Zip Code:74462-1652
Practice Address - Country:US
Practice Address - Phone:918-630-6842
Practice Address - Fax:918-967-8203
Is Sole Proprietor?:No
Enumeration Date:2012-01-23
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5148-P1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200418870AMedicaid