Healthcare Provider Details

I. General information

NPI: 1093086654
Provider Name (Legal Business Name): JACQUELYN RENAE TRAVERS PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JACQUELYN RENAE PEARSE

II. Dates (important events)

Enumeration Date: 01/13/2012
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1122 NE 13TH ST # 4403
OKLAHOMA CITY OK
73117-1039
US

IV. Provider business mailing address

508 SPARROW HAWK
EDMOND OK
73003-3174
US

V. Phone/Fax

Practice location:
  • Phone: 405-388-5119
  • Fax:
Mailing address:
  • Phone: 405-388-5119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number14727
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: