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General NPI Number Information
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NPI Number | 1396970976
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Entity Type | Organization
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Legal Business Name | INGRID W JACKSON MD INC. P.C.
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Dates
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Enumeration Date | 05/26/2009
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Last Update Date | 05/26/2009
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Provider Practice Location Address
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Address Line | 13321 N MERIDIAN AVE STE 314
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City | OKLAHOMA CITY
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State | OK
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Zip | 73120-8356
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Country | US
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Telephone | 405-470-7189
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Fax | 405-470-7712
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Provider Business Mailing Address
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Address Line | 6957 NW EXPRESSWAY # 254
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City | OKLAHOMA CITY
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State | OK
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Zip | 73132-3533
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Country | US
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Telephone | 405-473-7927
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Fax | 405-470-7712
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | DR. INGRID WORRELL JACKSON
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Credential | M.D.
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Telephone | 405-473-7927
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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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