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General NPI Number Information
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NPI Number | 1902263270
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Entity Type | Individual
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Provider Name | CARL JACKSON PA-C
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Gender | Male
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Dates
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Enumeration Date | 01/18/2016
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Last Update Date | 01/18/2016
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Provider Practice Location Address
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Address Line | 8801 S 101ST EAST AVE
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City | TULSA
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State | OK
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Zip | 74133-5716
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Country | US
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Telephone | 918-579-6090
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Fax |
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Provider Business Mailing Address
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Address Line | 22096 S 445TH EAST AVE
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City | PORTER
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State | OK
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Zip | 74454-3239
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Country | US
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Telephone | 918-625-7927
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA 2616
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License Number State | OK
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