Provider Demographics
NPI:1346882032
Name:ROBERSON, JAQUETTA JARAE (APRN-CNP)
Entity Type:Individual
Prefix:
First Name:JAQUETTA
Middle Name:JARAE
Last Name:ROBERSON
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 12TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-5722
Mailing Address - Country:US
Mailing Address - Phone:580-223-3411
Mailing Address - Fax:580-226-6213
Practice Address - Street 1:20 12TH AVE NW
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-5722
Practice Address - Country:US
Practice Address - Phone:580-223-3411
Practice Address - Fax:580-226-6213
Is Sole Proprietor?:No
Enumeration Date:2019-10-14
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK110221363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care