Basic Information
| Provider Information | |||||||||
| NPI: | 1205470788 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | TAWNYA | ||||||||
| MiddleName: | |||||||||
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| Credential: | BA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1807 N HARTFORD ST APT 1111 | ||||||||
| Address2: | |||||||||
| City: | STILLWATER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740755782 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804914410 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 604 S WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | STILLWATER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740744222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053722202 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2019 | ||||||||
| LastUpdateDate: | 11/25/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.