Provider Demographics
NPI:1043749310
Name:ZUIDEMA, JAQ L (LCSW, ASDCS, TIYT)
Entity type:Individual
Prefix:
First Name:JAQ
Middle Name:L
Last Name:ZUIDEMA
Suffix:
Gender:X
Credentials:LCSW, ASDCS, TIYT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8263 S HARVARD AVE # 1015
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-1614
Mailing Address - Country:US
Mailing Address - Phone:918-558-0338
Mailing Address - Fax:
Practice Address - Street 1:8263 S HARVARD AVE # 1015
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-1614
Practice Address - Country:US
Practice Address - Phone:918-558-0338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-08
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 101YM0800X
OK212191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health