MEDICARE: SCOTTY JACKSON FNP-BC

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	363LF0000X	Family Nurse Practitioner	R0078720	OK
2	363LF0000X	Family Nurse Practitioner	211329	OK

General Provider Information

NPI Number	:	1750095980
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SCOTTY JACKSON FNP-BC

Provider Business Mailing Address
First Line	:	34550 AIRLINE RD
Second Line	:
City	:	PAULS VALLEY
State	:	OK
Zip	:	73075-9337
Country	:	US
Telephone Number	:	405-207-9238
Fax Number	:	405-207-9240

Provider Business Practice Location Address
First Line	:	34550 AIRLINE RD
Second Line	:
City	:	PAULS VALLEY
State	:	OK
Zip	:	73075-9337
Country	:	US
Telephone Number	:	405-207-9238
Fax Number	:	405-207-9240

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

Provider Enumeration Date	:	01/11/2023
Last Update Date	:	07/11/2023

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