Provider Demographics
NPI:1790818631
Name:BRASHEAR, JACQUELINE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:BRASHEAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8270 E. 71ST ST.
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-2908
Mailing Address - Country:US
Mailing Address - Phone:918-250-0180
Mailing Address - Fax:918-250-8508
Practice Address - Street 1:8270 E . 71ST ST.
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-2908
Practice Address - Country:US
Practice Address - Phone:918-250-0180
Practice Address - Fax:918-250-8508
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK237987174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist