MEDICARE: MRS. JESSICA ELISE JACKSON PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant		OK
2	363A00000X	Physician Assistant	2725	OK

General Provider Information

NPI Number	:	1023553187
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JESSICA ELISE JACKSON PA-C

Provider Business Mailing Address
First Line	:	12220 GREENLEA CHASE W
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73170-6010
Country	:	US
Telephone Number	:	405-761-3256
Fax Number	:

Provider Business Practice Location Address
First Line	:	2109 S SANTA FE AVE
Second Line	:
City	:	MOORE
State	:	OK
Zip	:	73160-2807
Country	:	US
Telephone Number	:	405-213-0256
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/28/2016
Last Update Date	:	01/16/2020

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