Provider Demographics
NPI:1568763019
Name:STAFFORD, JACKIE DEE (APRN)
Entity Type:Individual
Prefix:MRS
First Name:JACKIE
Middle Name:DEE
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MRS
Other - First Name:JACKIE
Other - Middle Name:DEE
Other - Last Name:STAFFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:11150 HWY 49
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-3347
Mailing Address - Country:US
Mailing Address - Phone:228-831-1700
Mailing Address - Fax:918-488-6010
Practice Address - Street 1:6161 S YALE AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-1902
Practice Address - Country:US
Practice Address - Phone:918-502-1900
Practice Address - Fax:918-494-6303
Is Sole Proprietor?:No
Enumeration Date:2010-11-14
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK111885207Q00000X
MS813602363LF0000X
MSR813602163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily