Healthcare Provider Details

I. General information

NPI: 1962701391
Provider Name (Legal Business Name): DANA LYNN JACKSON LADC UNDER SUPER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2011
Last Update Date: 10/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2448 E. 81ST STREET SUITE 4824 / CITIPLEXTOWERS
TULSA OK
74137-1814
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: 405-310-6108
  • 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: