Provider Demographics
NPI:1154702256
Name:JACKIE HORTON LLC
Entity type:Organization
Organization Name:JACKIE HORTON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HORTON
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:580-399-5398
Mailing Address - Street 1:RR 4 BOX 854
Mailing Address - Street 2:
Mailing Address - City:COALGATE
Mailing Address - State:OK
Mailing Address - Zip Code:74538-9624
Mailing Address - Country:US
Mailing Address - Phone:580-399-5398
Mailing Address - Fax:580-927-2346
Practice Address - Street 1:RR 4 BOX 854
Practice Address - Street 2:
Practice Address - City:COALGATE
Practice Address - State:OK
Practice Address - Zip Code:74538-9624
Practice Address - Country:US
Practice Address - Phone:580-399-5398
Practice Address - Fax:580-927-2346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-15
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5730101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty