Provider Demographics
NPI:1093086654
Name:TRAVERS, JACQUELYN RENAE (PHARMD)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:RENAE
Last Name:TRAVERS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:RENAE
Other - Last Name:PEARSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:508 SPARROW HAWK DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003
Mailing Address - Country:US
Mailing Address - Phone:405-216-9612
Mailing Address - Fax:
Practice Address - Street 1:120 N BRYANT AVE
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-6302
Practice Address - Country:US
Practice Address - Phone:405-341-8490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-13
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK147271835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK164525OtherNABP