Healthcare Provider Details

I. General information

NPI: 1821832882
Provider Name (Legal Business Name): JACE JACKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2024
Last Update Date: 06/24/2024
Certification Date: 06/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 W 17TH ST
TULSA OK
74107-1886
US

IV. Provider business mailing address

3821 SOUTHRIDGE CIR APT 4
TAHLEQUAH OK
74464-7944
US

V. Phone/Fax

Practice location:
  • Phone: 918-582-1972
  • Fax:
Mailing address:
  • Phone: 405-570-9774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: