Healthcare Provider Details

I. General information

NPI: 1811856891
Provider Name (Legal Business Name): JESSICA NELL HOWARD MACK DNP, APRN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

61 MOCCASIN LN
SPAVINAW OK
74366-6603
US

IV. Provider business mailing address

61 MOCCASIN LN
SPAVINAW OK
74366-6603
US

V. Phone/Fax

Practice location:
  • Phone: 918-399-1361
  • Fax: 918-399-1361
Mailing address:
  • Phone: 918-399-1361
  • Fax: 918-399-1361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number229953
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: