Provider Demographics
NPI:1679711188
Name:JONES, BEVERLY SUE (REGISTERED NURSE)
Entity Type:Individual
Prefix:MS
First Name:BEVERLY
Middle Name:SUE
Last Name:JONES
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:MS
Other - First Name:BEVERLY
Other - Middle Name:SUE
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:REGISTERED NURSE
Mailing Address - Street 1:209 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:OKEMAH
Mailing Address - State:OK
Mailing Address - Zip Code:74859-2618
Mailing Address - Country:US
Mailing Address - Phone:918-623-2922
Mailing Address - Fax:918-623-9316
Practice Address - Street 1:209 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:OKEMAH
Practice Address - State:OK
Practice Address - Zip Code:74859-2618
Practice Address - Country:US
Practice Address - Phone:918-623-2922
Practice Address - Fax:918-623-9316
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-22
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR0046163163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100734620DMedicaid