Healthcare Provider Details

I. General information

NPI: 1558858068
Provider Name (Legal Business Name): JAMES JACKSON, MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2018
Last Update Date: 04/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3330 NW 56TH ST STE 612
OKLAHOMA CITY OK
73112-4470
US

IV. Provider business mailing address

13924 QUAIL POINTE DR STE B
OKLAHOMA CITY OK
73134-1024
US

V. Phone/Fax

Practice location:
  • Phone: 405-610-8810
  • Fax:
Mailing address:
  • Phone: 405-896-7901
  • Fax: 405-242-4074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number27258
License Number StateOK

VIII. Authorized Official

Name: TAWANA HILL
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 405-896-7901