Basic Information
| Provider Information | |||||||||
| NPI: | 1043538226 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | BRITTANY | ||||||||
| MiddleName: | ALISE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1338 E 58TH ST | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741058501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9188419596 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4528 S SHERIDAN RD STE 117 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741451101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187946570 | ||||||||
| FaxNumber: | 9183405189 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2010 | ||||||||
| LastUpdateDate: | 01/05/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.