Provider Demographics
NPI:1881128775
Name:FROESE, JACQUELINE R (APRN)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:R
Last Name:FROESE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:R
Other - Last Name:WADE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1120 S UTICA AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4012
Mailing Address - Country:US
Mailing Address - Phone:918-560-3823
Mailing Address - Fax:918-560-5761
Practice Address - Street 1:1145 S UTICA AVE
Practice Address - Street 2:STE 110
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4000
Practice Address - Country:US
Practice Address - Phone:918-560-3823
Practice Address - Fax:918-560-5761
Is Sole Proprietor?:No
Enumeration Date:2017-04-18
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK123756363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily