Provider Demographics
NPI:1972697696
Name:WOOLDRIDGE, JACQUELYN MARIE (CNS)
Entity type:Individual
Prefix:MS
First Name:JACQUELYN
Middle Name:MARIE
Last Name:WOOLDRIDGE
Suffix:
Gender:F
Credentials:CNS
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 2526
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803-2526
Mailing Address - Country:US
Mailing Address - Phone:417-347-7540
Mailing Address - Fax:417-347-7549
Practice Address - Street 1:3901 E 32ND ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-3312
Practice Address - Country:US
Practice Address - Phone:417-347-7540
Practice Address - Fax:417-347-7549
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000174217364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO425193406Medicaid
MO000081134Medicare ID - Type Unspecified
MOR17112Medicare UPIN