Provider Demographics
NPI:1154767812
Name:JOHNDROW, JACLYN (LPC S)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:JOHNDROW
Suffix:
Gender:F
Credentials:LPC S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1608 E GRANGER ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-8311
Mailing Address - Country:US
Mailing Address - Phone:918-381-5292
Mailing Address - Fax:
Practice Address - Street 1:1608 E GRANGER ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-8311
Practice Address - Country:US
Practice Address - Phone:918-381-5292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-21
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
OK5937101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst