Healthcare Provider Details

I. General information

NPI: 1972697696
Provider Name (Legal Business Name): JACQUELYN MARIE WOOLDRIDGE CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 04/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 E 32ND ST
JOPLIN MO
64804-3312
US

IV. Provider business mailing address

PO BOX 2526
JOPLIN MO
64803-2526
US

V. Phone/Fax

Practice location:
  • Phone: 417-347-7540
  • Fax: 417-347-7549
Mailing address:
  • Phone: 417-347-7540
  • Fax: 417-347-7549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number2000174217
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: