Provider Demographics
NPI:1023155645
Name:FORTENBERRY, JACK L (LMSW)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:L
Last Name:FORTENBERRY
Suffix:
Gender:M
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:PO BOX 695
Mailing Address - Street 2:
Mailing Address - City:CHOCTAW
Mailing Address - State:OK
Mailing Address - Zip Code:73020-0695
Mailing Address - Country:US
Mailing Address - Phone:405-390-8131
Mailing Address - Fax:405-390-8134
Practice Address - Street 1:14625 NE 23RD STREET
Practice Address - Street 2:
Practice Address - City:CHOCTAW
Practice Address - State:OK
Practice Address - Zip Code:73020
Practice Address - Country:US
Practice Address - Phone:405-390-8131
Practice Address - Fax:405-390-8134
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3030101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor