Provider Demographics
NPI:1831162502
Name:JERNIGAN, TRACEY LEA (LCSW)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:LEA
Last Name:JERNIGAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:LEA
Other - Last Name:PRICHARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 16337
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73113-2337
Mailing Address - Country:US
Mailing Address - Phone:405-840-2391
Mailing Address - Fax:405-840-2394
Practice Address - Street 1:6406 N SANTA FE AVE
Practice Address - Street 2:SUITE C
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-9111
Practice Address - Country:US
Practice Address - Phone:405-840-2391
Practice Address - Fax:405-840-2394
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-10
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100723600BMedicaid