Provider Demographics
NPI:1124346317
Name:JENNINGS, TRACEY MIDDLETON (MSW, LCSW, LADC)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:MIDDLETON
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:MSW, LCSW, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2990 N SIOUX AVE
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74017-3700
Mailing Address - Country:US
Mailing Address - Phone:918-342-2622
Mailing Address - Fax:918-342-2641
Practice Address - Street 1:8937 S GARNETT RD
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-6004
Practice Address - Country:US
Practice Address - Phone:918-872-9777
Practice Address - Fax:918-872-9779
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-12
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
OK1033101YA0400X
OK39631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK3963OtherLICENSE