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General NPI Number Information
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NPI Number | 1205336187
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Entity Type | Organization
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Legal Business Name | INGRID W. JACKSON, M.D., LLC
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Dates
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Enumeration Date | 02/16/2018
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Last Update Date | 10/28/2024
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Provider Practice Location Address
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Address Line | 740 SIGNAL RIDGE DR
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City | EDMOND
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State | OK
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Zip | 73013-3675
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Country | US
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Telephone | 405-418-0125
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Fax | 405-216-3454
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Provider Business Mailing Address
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Address Line | 740 SIGNAL RIDGE DR
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City | EDMOND
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State | OK
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Zip | 73013-3675
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Country | US
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Telephone | 405-418-0125
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Fax | 405-216-3454
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Authorized Official
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Title or Position | OWNER
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Name | TINA WHITE
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Credential |
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Telephone | 405-418-0125
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 15786
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License Number State | OK
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