Provider Demographics
NPI:1801874805
Name:MOORE, JACQUELINE (ARNP)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6600 S YALE AVE
Mailing Address - Street 2:STE 1400
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3310
Mailing Address - Country:US
Mailing Address - Phone:918-488-6001
Mailing Address - Fax:918-488-6010
Practice Address - Street 1:6600 S YALE AVE
Practice Address - Street 2:STE 650
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-3310
Practice Address - Country:US
Practice Address - Phone:918-502-7200
Practice Address - Fax:918-502-7205
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0033672363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKS81539Medicare UPIN
OK$$$$$$$$$Medicare PIN