Provider Demographics
NPI:1285909705
Name:POLEN, JON S (MS , LPC)
Entity type:Individual
Prefix:MR
First Name:JON
Middle Name:S
Last Name:POLEN
Suffix:
Gender:M
Credentials:MS , LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1860 E 15TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4611
Mailing Address - Country:US
Mailing Address - Phone:918-949-4430
Mailing Address - Fax:918-949-4431
Practice Address - Street 1:606 KIHEKAH AVE
Practice Address - Street 2:
Practice Address - City:PAWHUSKA
Practice Address - State:OK
Practice Address - Zip Code:74056-4225
Practice Address - Country:US
Practice Address - Phone:918-287-5426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-16
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6120101YM0800X
171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171W00000XOther Service ProvidersContractor