Provider Demographics
NPI:1700364387
Name:ROSE, JACKLYN DAWN (FNP-BC)
Entity Type:Individual
Prefix:
First Name:JACKLYN
Middle Name:DAWN
Last Name:ROSE
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 E TAFT AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-5651
Mailing Address - Country:US
Mailing Address - Phone:918-224-2222
Mailing Address - Fax:
Practice Address - Street 1:303 E TAFT AVE STE 3
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-5651
Practice Address - Country:US
Practice Address - Phone:918-224-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-05
Last Update Date:2018-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK92995363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily