Basic Information
| Provider Information | |||||||||
| NPI: | 1134629405 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APRN, CNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 2339 | ||||||||
| Address2: | |||||||||
| City: | ELK CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 736482339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802252518 | ||||||||
| FaxNumber: | 5802253167 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 W 1ST ST STE 105B | ||||||||
| Address2: | |||||||||
| City: | ELK CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 736443133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802252518 | ||||||||
| FaxNumber: | 5802253167 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2018 | ||||||||
| LastUpdateDate: | 03/26/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 113330 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 163WM0705X | 113330 | OK | N | Nursing Service Providers | Registered Nurse | Medical-Surgical |
No ID Information.