Healthcare Provider Details

I. General information

NPI: 1023648607
Provider Name (Legal Business Name): COURTNEY DYANE JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: COURTNEY DYANE TOOMBS

II. Dates (important events)

Enumeration Date: 01/22/2020
Last Update Date: 08/07/2025
Certification Date: 08/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2425 W UNIVERSITY BLVD
DURANT OK
74701-2942
US

IV. Provider business mailing address

PO BOX 189
ARDMORE OK
73402-0189
US

V. Phone/Fax

Practice location:
  • Phone: 580-924-7330
  • Fax:
Mailing address:
  • Phone: 580-980-0674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: