MEDICARE: TONYA WARD JACKSON OD PC

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	152W00000X	Optometrist	1196	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1205017779
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TONYA WARD JACKSON OD PC

Provider Business Mailing Address
First Line	:	8010 S 101ST EAST AVE
Second Line	:	SUITE 100
City	:	TULSA
State	:	OK
Zip	:	74133-4562
Country	:	US
Telephone Number	:	918-252-7432
Fax Number	:	918-250-9003

Provider Business Practice Location Address
First Line	:	8010 S 101ST EAST AVE
Second Line	:	SUITE 100
City	:	TULSA
State	:	OK
Zip	:	74133-4562
Country	:	US
Telephone Number	:	918-252-7432
Fax Number	:	918-250-9003

Authorized Official
Title or Position	:	OPTOMETRIST
Name	:	DR. TONYA W JACKSON
Credential	:	OD
Telephone Number	:	918-252-7432

Provider Enumeration Date	:	11/26/2007
Last Update Date	:	04/16/2009

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