MEDICARE: MRS. CANDICE 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	101Y00000X	Counselor

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	:	1346490042
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CANDICE JACKSON

Provider Business Mailing Address
First Line	:	PO BOX 720477
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73172-0477
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11614 VAIL DR
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73162-1644
Country	:	US
Telephone Number	:	405-388-6048
Fax Number	:

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

Provider Enumeration Date	:	09/30/2008
Last Update Date	:	09/11/2013

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