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NPI Code Detail

MEDICARE: KENNETH C JACKSON M.D.

MEDICARE: KENNETH C JACKSON M.D.
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
1174400000XSpecialist11030OK

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
111030OTHEROKLICENSE

General Provider Information

NPI Number : 1457491037
Entity Type Code : Individual
Provider Name (Legal Business Name) : KENNETH C JACKSON M.D.
Provider Business Mailing Address
First Line : 7301 N COMANCHE AVE
Second Line :
City : WARR ACRES
State : OK
Zip : 73132-6646
Country : US
Telephone Number : 405-721-8090
Fax Number : 405-722-8529
Provider Business Practice Location Address
First Line : 7301 N COMANCHE AVE
Second Line : OU PHYSICIANS
City : WARR ACRES
State : OK
Zip : 73132-6646
Country : US
Telephone Number : 405-721-8090
Fax Number : 405-722-8529
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/06/2007
Last Update Date : 03/07/2023

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