Provider Demographics
NPI:1932826781
Name:BANTLE, JENNIFER (LCSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BANTLE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 BRONZE MEDAL RD
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-7971
Mailing Address - Country:US
Mailing Address - Phone:405-590-6397
Mailing Address - Fax:405-271-3052
Practice Address - Street 1:909 BRONZE MEDAL RD
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-7971
Practice Address - Country:US
Practice Address - Phone:405-590-6397
Practice Address - Fax:405-271-3052
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK25871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical