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General NPI Number Information
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NPI Number | 1194755793
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Entity Type | Individual
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Provider Name | MICHAEL S JACKSON MD
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Gender | Male
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Dates
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Enumeration Date | 07/03/2006
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Last Update Date | 09/09/2020
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Provider Practice Location Address
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Address Line | 620 S MADISON ST STE 304
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City | ENID
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State | OK
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Zip | 73701-7270
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Country | US
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Telephone | 580-233-6350
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Fax | 580-233-6106
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Provider Business Mailing Address
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Address Line | 5300 N INDEPENDENCE AVE 280
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City | OKLAHOMA CITY
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State | OK
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Zip | 73112-5556
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Country | US
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Telephone | 580-233-6350
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Fax | 580-233-6106
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number | 04-28958
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License Number State | KS
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Taxonomy #2
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number | 30290
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License Number State | OK
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