Provider Demographics
NPI:1194459362
Name:PURNELL, JACLYN NICHOLE
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:NICHOLE
Last Name:PURNELL
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 1:909 LINN AVE
Mailing Address - Street 2:
Mailing Address - City:WAGONER
Mailing Address - State:OK
Mailing Address - Zip Code:74467-2132
Mailing Address - Country:US
Mailing Address - Phone:405-220-7173
Mailing Address - Fax:
Practice Address - Street 1:118 W KEETOOWAH ST
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-3820
Practice Address - Country:US
Practice Address - Phone:918-708-2015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-13
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No251B00000XAgenciesCase Management