Provider Demographics
NPI:1700302833
Name:JAMISON, GRACIE (LPC)
Entity type:Individual
Prefix:
First Name:GRACIE
Middle Name:
Last Name:JAMISON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 W SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-6133
Mailing Address - Country:US
Mailing Address - Phone:580-749-5056
Mailing Address - Fax:580-215-5756
Practice Address - Street 1:407 W SOUTH AVE
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-6133
Practice Address - Country:US
Practice Address - Phone:580-749-5056
Practice Address - Fax:580-215-5756
Is Sole Proprietor?:No
Enumeration Date:2017-08-21
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7137101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health