Healthcare Provider Details

I. General information

NPI: 1003279498
Provider Name (Legal Business Name): JARED QUALLS APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2016
Last Update Date: 06/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1145 S UTICA AVE SUITE 460
TULSA OK
74104-4000
US

IV. Provider business mailing address

1145 S UTICA AVE SUITE 460
TULSA OK
74104-4000
US

V. Phone/Fax

Practice location:
  • Phone: 918-579-5749
  • Fax: 918-579-5762
Mailing address:
  • Phone: 918-579-5749
  • Fax: 918-579-5762

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number102252
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number102252
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: