MEDICARE: DR. MICHAEL S JACKSON MD

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	207V00000X	Obstetrics & Gynecology Physician	04-28958	KS
2	207V00000X	Obstetrics & Gynecology Physician	30290	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1194755793
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL S JACKSON MD

Provider Business Mailing Address
First Line	:	5300 N INDEPENDENCE AVE
Second Line	:	280
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-5556
Country	:	US
Telephone Number	:	580-233-6350
Fax Number	:	580-233-6106

Provider Business Practice Location Address
First Line	:	620 S MADISON ST STE 304
Second Line	:
City	:	ENID
State	:	OK
Zip	:	73701-7270
Country	:	US
Telephone Number	:	580-233-6350
Fax Number	:	580-233-6106

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

Provider Enumeration Date	:	07/03/2006
Last Update Date	:	09/09/2020

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Directions to “ DR. MICHAEL S JACKSON MD” Practice Location

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