Healthcare Provider Details

I. General information

NPI: 1790004901
Provider Name (Legal Business Name): MR. ROBERT LAWRENCE JACKSON JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2010
Last Update Date: 10/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2448 E 81ST ST SUITE 4824 / CITIPLEXTOWERS
TULSA OK
74137-4250
US

IV. Provider business mailing address

2413 LARKHAVEN ST
NORMAN OK
73071-4326
US

V. Phone/Fax

Practice location:
  • Phone: 918-486-9996
  • Fax:
Mailing address:
  • Phone: 405-216-5608
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: