1619133790 NPI number — MRS. JEANICE L POLWORT M.ED, LPC

Table of content: MRS. JEANICE L POLWORT M.ED, LPC (NPI 1619133790)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619133790 NPI number — MRS. JEANICE L POLWORT M.ED, LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POLWORT
Provider First Name:
JEANICE
Provider Middle Name:
L
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.ED, LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619133790
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/01/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2112 E MAPLE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ENID
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73701-4612
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-747-2289
Provider Business Mailing Address Fax Number:
580-234-3553

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1522 RAMONA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ENID
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73703-7021
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-747-2289
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  4412 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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