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General NPI Number Information
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NPI Number | 1821885229
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Entity Type | Individual
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Provider Name | KEALAH NICOLE JACKSON
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Gender | Female
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Dates
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Enumeration Date | 04/21/2025
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Last Update Date | 04/21/2025
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Provider Practice Location Address
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Address Line | 4016 SE 48TH ST
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City | OKLAHOMA CITY
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State | OK
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Zip | 73135-2202
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Country | US
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Telephone | 405-931-8552
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Fax |
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Provider Business Mailing Address
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Address Line | 416 W 15TH ST STE 600
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City | EDMOND
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State | OK
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Zip | 73013-3672
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Country | US
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Telephone | 405-562-6072
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Fax |
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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 | 172A00000X
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Taxonomy Name | Driver
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License Number | A088146885
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License Number State | OK
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