Basic Information
| Provider Information | |||||||||
| NPI: | 1689612939 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | R | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5199 | ||||||||
| Address2: | |||||||||
| City: | ABILENE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 796085199 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3254378300 | ||||||||
| FaxNumber: | 3254378399 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 N UNIVERSITY DR | ||||||||
| Address2: | |||||||||
| City: | EDMOND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730345207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059742317 | ||||||||
| FaxNumber: | 4059743832 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R0036896 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.