Provider Demographics
NPI:1972260099
Name:BULLEN, JENNA
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:BULLEN
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 1:9508 NW 89TH ST
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-9308
Mailing Address - Country:US
Mailing Address - Phone:405-535-1556
Mailing Address - Fax:
Practice Address - Street 1:1737 LINWOOD BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73106-5033
Practice Address - Country:US
Practice Address - Phone:405-706-8808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-23
Last Update Date:2024-08-23
Deactivation Date:2024-08-13
Deactivation Code:
Reactivation Date:2024-08-22
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OK101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator