MEDICARE: JIMMIE K JACKSON MD

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	208600000X	Surgery Physician	8567	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	:	1891761599
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JIMMIE K JACKSON MD

Provider Business Mailing Address
First Line	:	1237 GLENBROOK DR
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73118-1021
Country	:	US
Telephone Number	:	405-659-7578
Fax Number	:	405-232-3767

Provider Business Practice Location Address
First Line	:	1237 GLENBROOK DR
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73118-1021
Country	:	US
Telephone Number	:	405-659-7578
Fax Number	:	405-232-3767

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

Provider Enumeration Date	:	02/23/2006
Last Update Date	:	04/10/2017

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