Basic Information
| Provider Information | |||||||||
| NPI: | 1194755793 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5300 N INDEPENDENCE AVE | ||||||||
| Address2: | 280 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731125556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802336350 | ||||||||
| FaxNumber: | 5802336106 | ||||||||
| Practice Location | |||||||||
| Address1: | 620 S MADISON ST STE 304 | ||||||||
| Address2: | |||||||||
| City: | ENID | ||||||||
| State: | OK | ||||||||
| PostalCode: | 737017270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802336350 | ||||||||
| FaxNumber: | 5802336106 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 09/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 04-28958 | KS | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 30290 | OK | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 100387680A | 05 | KS | MEDICAID | 100387680H | 05 | KS | MEDICAID |