Provider Demographics
NPI:1043691223
Name:JACKSON, SIERRA
Entity Type:Individual
Prefix:
First Name:SIERRA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SIERRA
Other - Middle Name:
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8433 WOODBEND DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73135-6186
Mailing Address - Country:US
Mailing Address - Phone:405-819-2321
Mailing Address - Fax:
Practice Address - Street 1:8433 WOODBEND DR
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73135-6186
Practice Address - Country:US
Practice Address - Phone:405-819-2321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-14
Last Update Date:2023-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
OK101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health