Healthcare Provider Details

I. General information

NPI: 1639169337
Provider Name (Legal Business Name): JACKIE J PARNELL PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 09/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 S BROADWAY
COWETA OK
74429-5000
US

IV. Provider business mailing address

15187 W GRANDVIEW RD
TAHLEQUAH OK
74464-1118
US

V. Phone/Fax

Practice location:
  • Phone: 918-486-5564
  • Fax: 918-486-3284
Mailing address:
  • Phone: 918-316-2200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number552
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: