Healthcare Provider Details

I. General information

NPI: 1205181559
Provider Name (Legal Business Name): JACQUELINE SUE ROLLINS CP-N
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2012
Last Update Date: 02/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 N. BROADWAY
BROKEN BOW OK
74728-5304
US

IV. Provider business mailing address

3310 LAMAR AVE
PARIS TX
75460-5024
US

V. Phone/Fax

Practice location:
  • Phone: 580-236-4314
  • Fax:
Mailing address:
  • Phone: 903-905-4810
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR0041400
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: