=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013771161
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KYLEE JACKSON FNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2024
-----------------------------------------------------
Last Update Date | 02/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4444 S HARVARD AVE STE 300
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74135-2611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-992-6400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1294
-----------------------------------------------------
City | INOLA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74036-1294
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-693-8393
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 216736
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------