Provider Demographics
NPI:1346235488
Name:GILLESPIE, JACQUELINE L (ARNP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:L
Last Name:GILLESPIE
Suffix:
Gender:F
Credentials:ARNP
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 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-312-7605
Mailing Address - Fax:605-312-7611
Practice Address - Street 1:2502 W ELK AVE
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:OK
Practice Address - Zip Code:73533-1562
Practice Address - Country:US
Practice Address - Phone:580-252-9600
Practice Address - Fax:580-252-6100
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0045906163WP0200X
OK45906363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100113640AMedicaid
OK100113640BOtherSOONERCARE CHOICE-LAWTON
P29750Medicare UPIN