Provider Demographics
NPI:1124821202
Name:HURST, JACQLYN NICOLE (APRN-PNP)
Entity type:Individual
Prefix:
First Name:JACQLYN
Middle Name:NICOLE
Last Name:HURST
Suffix:
Gender:
Credentials:APRN-PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5025 S IRVINGTON CT
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-6816
Mailing Address - Country:US
Mailing Address - Phone:918-520-7078
Mailing Address - Fax:
Practice Address - Street 1:715 W MAIN ST
Practice Address - Street 2:
Practice Address - City:JENKS
Practice Address - State:OK
Practice Address - Zip Code:74037-3554
Practice Address - Country:US
Practice Address - Phone:918-745-0501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-01
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK222535363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics