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NPI Code Detail

MEDICARE: MS. ANDREA LUTHELLE JACKSON M.S. EDUCATION

MEDICARE: MS. ANDREA LUTHELLE JACKSON M.S. EDUCATION
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
1101YM0800XMental Health Counselor

General Provider Information

NPI Number : 1124383765
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. ANDREA LUTHELLE JACKSON M.S. EDUCATION
Provider Business Mailing Address
First Line : 1501 NW 34TH ST
Second Line :
City : OKLAHOMA CITY
State : OK
Zip : 73118-3203
Country : US
Telephone Number : 405-223-7793
Fax Number :
Provider Business Practice Location Address
First Line : 1501 NW 34TH ST
Second Line :
City : OKLAHOMA CITY
State : OK
Zip : 73118-3203
Country : US
Telephone Number : 405-223-7793
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/10/2012
Last Update Date : 07/10/2012

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