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NPI Code Detail

MEDICARE: GWEN D JACKSON RBT

MEDICARE: GWEN D JACKSON RBT
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
1106S00000XBehavior TechnicianRBT-22-251702TX

General Provider Information

NPI Number : 1366123838
Entity Type Code : Individual
Provider Name (Legal Business Name) : GWEN D JACKSON RBT
Provider Business Mailing Address
First Line : 330 W EDMOND RD
Second Line :
City : EDMOND
State : OK
Zip : 73003-5600
Country : US
Telephone Number : 405-216-3391
Fax Number : 405-216-3391
Provider Business Practice Location Address
First Line : 330 W EDMOND RD
Second Line :
City : EDMOND
State : OK
Zip : 73003-5600
Country : US
Telephone Number : 405-216-3391
Fax Number : 405-216-3391
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/27/2023
Last Update Date : 02/21/2025

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Directions to “ GWEN D JACKSON RBT” Practice Location

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