Healthcare Provider Details

I. General information

NPI: 1205017779
Provider Name (Legal Business Name): TONYA WARD JACKSON OD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2007
Last Update Date: 04/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8010 S 101ST EAST AVE SUITE 100
TULSA OK
74133-4562
US

IV. Provider business mailing address

8010 S 101ST EAST AVE SUITE 100
TULSA OK
74133-4562
US

V. Phone/Fax

Practice location:
  • Phone: 918-252-7432
  • Fax: 918-250-9003
Mailing address:
  • Phone: 918-252-7432
  • Fax: 918-250-9003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1196
License Number StateOK

VIII. Authorized Official

Name: DR. TONYA W JACKSON
Title or Position: OPTOMETRIST
Credential: OD
Phone: 918-252-7432