Healthcare Provider Details

I. General information

NPI: 1790880011
Provider Name (Legal Business Name): KYNDRA ASHANTA JACKSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 MOW-WAY ROAD REYNOLDS ACH (ATTN: MCUA-QC, MS. PRESCOTT)
FORT SILL OK
73503-6300
US

IV. Provider business mailing address

4301 MOW-WAY ROAD REYNOLDS ACH (ATTN: MCUA-QC, MS. PRESCOTT)
FORT SILL OK
73503-6300
US

V. Phone/Fax

Practice location:
  • Phone: 580-458-2134
  • Fax: 580-458-2314
Mailing address:
  • Phone: 580-458-2134
  • Fax: 580-458-2314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberR153354
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: