Provider Demographics
NPI:1023553187
Name:JACKSON, JESSICA ELISE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:ELISE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12220 GREENLEA CHASE W
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73170-6010
Mailing Address - Country:US
Mailing Address - Phone:405-761-3256
Mailing Address - Fax:
Practice Address - Street 1:2109 S SANTA FE AVE
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-2807
Practice Address - Country:US
Practice Address - Phone:405-213-0256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-28
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK363A00000X
OK2725363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant