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General NPI Number Information
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NPI Number | 1093086654
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Entity Type | Individual
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Provider Name | JACQUELYN RENAE TRAVERS PHARMD
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Gender | Female
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Dates
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Enumeration Date | 01/13/2012
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Last Update Date | 01/13/2012
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Provider Practice Location Address
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Address Line | 120 N BRYANT AVE
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City | EDMOND
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State | OK
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Zip | 73034-6302
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Country | US
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Telephone | 405-341-8490
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Fax |
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Provider Business Mailing Address
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Address Line | 508 SPARROW HAWK DR
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City | EDMOND
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State | OK
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Zip | 73003
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Country | US
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Telephone | 405-216-9612
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1835P1200X
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Taxonomy Name | Pharmacotherapy Pharmacist
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License Number | 14727
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License Number State | OK
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