MEDICARE: MRS. MARY ELIZABETH 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

General Provider Information

NPI Number	:	1659620268
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARY ELIZABETH JACKSON

Provider Business Mailing Address
First Line	:	4101 PERIMETER CENTER DR
Second Line	:	SUITE 250
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-2302
Country	:	US
Telephone Number	:	405-751-0800
Fax Number	:	405-751-6488

Provider Business Practice Location Address
First Line	:	4101 PERIMETER CENTER DR
Second Line	:	SUITE 250
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-2302
Country	:	US
Telephone Number	:	405-751-0800
Fax Number	:	405-751-6488

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

Provider Enumeration Date	:	08/29/2012
Last Update Date	:	10/08/2013

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