Basic Information
Provider Information | |||||||||
NPI: | 1760646392 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JACKSON | ||||||||
FirstName: | JAMES | ||||||||
MiddleName: | JASON | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 13924 QUAIL POINTE DR STE B | ||||||||
Address2: |   | ||||||||
City: | OKLAHOMA CITY | ||||||||
State: | OK | ||||||||
PostalCode: | 731341024 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4058967901 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3330 NW 56TH ST STE 612 | ||||||||
Address2: |   | ||||||||
City: | OKLAHOMA CITY | ||||||||
State: | OK | ||||||||
PostalCode: | 731124470 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4056018810 | ||||||||
FaxNumber: | 4056018846 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/13/2008 | ||||||||
LastUpdateDate: | 03/26/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 50665 | MN | N |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   | 208100000X | 27258 | OK | N |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   | 202K00000X | 27258 | OK | Y |   | Allopathic & Osteopathic Physicians | Phlebology |   |
No ID Information.