Provider Demographics
NPI:1366876708
Name:JEFFCOAT, LISA DIANNE
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:DIANNE
Last Name:JEFFCOAT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3015 E SKELLY DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-6317
Mailing Address - Country:US
Mailing Address - Phone:918-712-0859
Mailing Address - Fax:918-388-9708
Practice Address - Street 1:3015 E SKELLY DR
Practice Address - Street 2:SUITE 103
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105-6317
Practice Address - Country:US
Practice Address - Phone:918-712-0859
Practice Address - Fax:918-388-9708
Is Sole Proprietor?:No
Enumeration Date:2013-08-21
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100746170UMedicaid
OK100746170GMedicaid