Provider Demographics
NPI:1558893354
Name:CARPENTER, JACKIE LYNN
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:LYNN
Last Name:CARPENTER
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 1:4519 NW CHEYENNE AVE
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-3244
Mailing Address - Country:US
Mailing Address - Phone:580-301-4839
Mailing Address - Fax:
Practice Address - Street 1:2215 NW CACHE RD
Practice Address - Street 2:SUITE 107
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-5239
Practice Address - Country:US
Practice Address - Phone:580-351-9998
Practice Address - Fax:580-351-9898
Is Sole Proprietor?:No
Enumeration Date:2017-03-30
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst