Provider Demographics
NPI:1861161176
Name:EVANS, JACQUELINE ELOISE (MSW)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ELOISE
Last Name:EVANS
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4916 S PITTSBURG AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-3110
Mailing Address - Country:US
Mailing Address - Phone:918-812-4953
Mailing Address - Fax:
Practice Address - Street 1:6216 S LEWIS AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-1044
Practice Address - Country:US
Practice Address - Phone:918-960-7852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8073-P1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical