Healthcare Provider Details

I. General information

NPI: 1194654152
Provider Name (Legal Business Name): KENDRA JACKSON B.A, M.ED.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2026
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 S 7TH AVE
DURANT OK
74701-5017
US

IV. Provider business mailing address

129 SUMMIT CIR
DURANT OK
74701-7438
US

V. Phone/Fax

Practice location:
  • Phone: 580-924-4779
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: