Healthcare Provider Details

I. General information

NPI: 1669433546
Provider Name (Legal Business Name): JOHN CLAUDE JACKSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MICHAEL DOUGLAS GORMAN M.D.

II. Dates (important events)

Enumeration Date: 03/30/2006
Last Update Date: 03/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 E CHEROKEE ST
WAGONER OK
74467-4708
US

IV. Provider business mailing address

410 E CHEROKEE ST
WAGONER OK
74467-4708
US

V. Phone/Fax

Practice location:
  • Phone: 918-485-5591
  • Fax: 918-485-5758
Mailing address:
  • Phone: 918-485-5591
  • Fax: 918-485-5758

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1672
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: