Healthcare Provider Details

I. General information

NPI: 1285944538
Provider Name (Legal Business Name): LINDA JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2010
Last Update Date: 01/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2817 SE 47TH ST
OKLAHOMA CITY OK
73129-8727
US

IV. Provider business mailing address

PO BOX 11421
OKLAHOMA CITY OK
73136-0421
US

V. Phone/Fax

Practice location:
  • Phone: 405-788-5687
  • Fax:
Mailing address:
  • Phone: 405-788-5687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number03156
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: