MEDICARE: ROBYN JACKSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	175T00000X	Peer Specialist

General Provider Information

NPI Number	:	1104568161
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBYN JACKSON

Provider Business Mailing Address
First Line	:	2133 SW 11TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73108-2615
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2133 SW 11TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73108-2615
Country	:	US
Telephone Number	:	405-412-3536
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/11/2022
Last Update Date	:	04/11/2022

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