Basic Information
| Provider Information | |||||||||
| NPI: | 1922404888 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ACOSTA-VAN DEN BERG | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | JENAE | ||||||||
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| Credential: | APRN-CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10321 N 2274 RD | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 736017521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803313300 | ||||||||
| FaxNumber: | 5803232579 | ||||||||
| Practice Location | |||||||||
| Address1: | 10321 N 2274 RD | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 736017521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803313300 | ||||||||
| FaxNumber: | 5803232579 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2014 | ||||||||
| LastUpdateDate: | 11/05/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 96005 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.