Provider Demographics
NPI:1447006119
Name:MICHAEL, JENNIFER TRACEY (LMSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:TRACEY
Last Name:MICHAEL
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:523 W ROANOKE ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74011-2430
Mailing Address - Country:US
Mailing Address - Phone:918-849-8384
Mailing Address - Fax:
Practice Address - Street 1:101 S MOORE AVE
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-5047
Practice Address - Country:US
Practice Address - Phone:918-342-6460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-24
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK201551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical