Healthcare Provider Details

I. General information

NPI: 1487399663
Provider Name (Legal Business Name): JACKIE L SHIPMAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2022
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 S PARK LN STE 200
ALTUS OK
73521-5731
US

IV. Provider business mailing address

1200 E PECAN ST
ALTUS OK
73521-6141
US

V. Phone/Fax

Practice location:
  • Phone: 580-379-6140
  • Fax: 580-379-6149
Mailing address:
  • Phone: 580-379-5000
  • Fax: 580-379-5509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number39741
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101286384
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number39741
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: