MEDICARE: TIFFANIE 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	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1639542301
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANIE JACKSON

Provider Business Mailing Address
First Line	:	725 PALMER DR
Second Line	:
City	:	MIDWEST CITY
State	:	OK
Zip	:	73110-8155
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	308 SW 25TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73109-5922
Country	:	US
Telephone Number	:	405-470-8778
Fax Number	:

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

Provider Enumeration Date	:	11/03/2015
Last Update Date	:	11/03/2015

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