Provider Demographics
NPI:1932416328
Name:JOHNSON, JACQUELINE BALLEW (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:BALLEW
Last Name:JOHNSON
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 1:908 NW 18TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73106-6415
Mailing Address - Country:US
Mailing Address - Phone:405-525-9080
Mailing Address - Fax:
Practice Address - Street 1:619 NW 23RD ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73103-1415
Practice Address - Country:US
Practice Address - Phone:405-528-0221
Practice Address - Fax:405-528-1517
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-07
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKROO68670363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health