Provider Demographics
NPI:1346882032
Name:STEVENSON, JAQUETTA JARAE (APRN-CNP)
Entity type:Individual
Prefix:
First Name:JAQUETTA
Middle Name:JARAE
Last Name:STEVENSON
Suffix:
Gender:
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 MICHELIN RD
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-1085
Mailing Address - Country:US
Mailing Address - Phone:580-224-8750
Mailing Address - Fax:
Practice Address - Street 1:1105 MICHELIN RD
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1085
Practice Address - Country:US
Practice Address - Phone:580-224-8750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-14
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK110221363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care