Provider Demographics
NPI:1124314588
Name:LOUDERMILK, JEANETTE (MA)
Entity type:Individual
Prefix:MISS
First Name:JEANETTE
Middle Name:
Last Name:LOUDERMILK
Suffix:
Gender:F
Credentials:MA
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 36434
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73136-2434
Mailing Address - Country:US
Mailing Address - Phone:405-818-8489
Mailing Address - Fax:
Practice Address - Street 1:3816 OAK VALLEY RD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73135-2055
Practice Address - Country:US
Practice Address - Phone:405-818-8489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-23
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5120101YM0800X, 101YA0400X, 101Y00000X, 101YP2500X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist