Healthcare Provider Details

I. General information

NPI: 1952368664
Provider Name (Legal Business Name): GRAND PRAIRIE PEDIATRIC AND ALLERGY CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 05/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7301 N COMANCHE AVE
OKLAHOMA CITY OK
73132
US

IV. Provider business mailing address

7301 N COMANCHE AVE
OKLAHOMA CITY OK
73132
US

V. Phone/Fax

Practice location:
  • Phone: 405-721-8090
  • Fax: 405-722-8529
Mailing address:
  • Phone: 405-721-8090
  • Fax: 405-722-8529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number11030
License Number StateOK

VIII. Authorized Official

Name: DR. KENNETH CHARLES JACKSON
Title or Position: PRES
Credential: MD
Phone: 405-721-8090