Provider Demographics
NPI:1730394875
Name:LEBLANC, JACQUELYN MARIE
Entity type:Individual
Prefix:DR
First Name:JACQUELYN
Middle Name:MARIE
Last Name:LEBLANC
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 1:5396 E 81ST ST APT 634
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-2261
Mailing Address - Country:US
Mailing Address - Phone:918-660-3577
Mailing Address - Fax:
Practice Address - Street 1:4502 E 41ST ST
Practice Address - Street 2:SUITE 2H23
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2553
Practice Address - Country:US
Practice Address - Phone:918-660-3577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK139071835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy