Provider Demographics
NPI:1326414947
Name:WILSON, JACQUELYN ANN (CNP)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:ANN
Last Name:WILSON
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 W MORROW RD
Mailing Address - Street 2:
Mailing Address - City:SAND SPRINGS
Mailing Address - State:OK
Mailing Address - Zip Code:74063-6549
Mailing Address - Country:US
Mailing Address - Phone:918-770-3134
Mailing Address - Fax:
Practice Address - Street 1:515 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:AUDUBON
Practice Address - State:IA
Practice Address - Zip Code:50025-1056
Practice Address - Country:US
Practice Address - Phone:712-563-2611
Practice Address - Fax:712-563-5248
Is Sole Proprietor?:No
Enumeration Date:2015-08-18
Last Update Date:2022-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA145802363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily