Provider Demographics
NPI:1699949792
Name:WHITE, JACQUELYN MARIE (MA, LPCA)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:MARIE
Last Name:WHITE
Suffix:
Gender:F
Credentials:MA, LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 S. PEORIA
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74120-4429
Mailing Address - Country:US
Mailing Address - Phone:918-587-9471
Mailing Address - Fax:918-560-0137
Practice Address - Street 1:2311 FORTUNE DR STE 201
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-4118
Practice Address - Country:US
Practice Address - Phone:859-253-1686
Practice Address - Fax:859-254-2743
Is Sole Proprietor?:No
Enumeration Date:2008-04-18
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101Y00000X
KY0723101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30615058Medicaid