Healthcare Provider Details

I. General information

NPI: 1124821202
Provider Name (Legal Business Name): JACQLYN NICOLE HURST APRN-PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2025
Last Update Date: 04/01/2025
Certification Date: 03/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 W MAIN ST
JENKS OK
74037-3554
US

IV. Provider business mailing address

5025 S IRVINGTON CT
TULSA OK
74135-6816
US

V. Phone/Fax

Practice location:
  • Phone: 918-745-0501
  • Fax:
Mailing address:
  • Phone: 918-520-7078
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number222535
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: