Provider Demographics
NPI:1285142877
Name:ANDERSON, JACQUELYN E (RN CHPN)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:E
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:RN CHPN
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 634
Mailing Address - Street 2:
Mailing Address - City:WARNER
Mailing Address - State:OK
Mailing Address - Zip Code:74469-0634
Mailing Address - Country:US
Mailing Address - Phone:918-577-2182
Mailing Address - Fax:
Practice Address - Street 1:1011 PRESIDENTS DRIVE
Practice Address - Street 2:
Practice Address - City:WARNER
Practice Address - State:OK
Practice Address - Zip Code:74469
Practice Address - Country:US
Practice Address - Phone:918-577-2182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-17
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX853333163W00000X
OK90912163WA0400X, 163WH1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH1000XNursing Service ProvidersRegistered NurseHospice
No163W00000XNursing Service ProvidersRegistered Nurse
No163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)