Healthcare Provider Details

I. General information

NPI: 1497057442
Provider Name (Legal Business Name): LATOYA NICHOLE JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2010
Last Update Date: 11/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 W 33RD ST
EDMOND OK
73013-3819
US

IV. Provider business mailing address

1500 MEYERS PL
OKLAHOMA CITY OK
73111-6014
US

V. Phone/Fax

Practice location:
  • Phone: 405-216-5608
  • Fax: 405-216-5272
Mailing address:
  • Phone: 405-921-3977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: