Provider Demographics
NPI:1033463088
Name:WOTHERSPOON, JAQUELYN BETH
Entity Type:Individual
Prefix:
First Name:JAQUELYN
Middle Name:BETH
Last Name:WOTHERSPOON
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 1:308 N KIMBERLY AVE
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74801-7514
Mailing Address - Country:US
Mailing Address - Phone:775-722-6941
Mailing Address - Fax:
Practice Address - Street 1:1336 N HARRISON AVE
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74801-5206
Practice Address - Country:US
Practice Address - Phone:405-424-7711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-30
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator