Healthcare Provider Details

I. General information

NPI: 1457594699
Provider Name (Legal Business Name): JACKSON MEDICAL CLINIC, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2009
Last Update Date: 03/22/2017
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 Code208D00000X
TaxonomyGeneral Practice Physician
License Number28153
License Number StateOK

VIII. Authorized Official

Name: KELLY NOEL HALEY
Title or Position: OFFICE MANAGER
Credential:
Phone: 918-485-5591