Provider Demographics
NPI:1043944754
Name:JACKSON, KAMERON R
Entity Type:Individual
Prefix:
First Name:KAMERON
Middle Name:R
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 CROWN POINT AVE APT 21
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-5866
Mailing Address - Country:US
Mailing Address - Phone:817-372-5098
Mailing Address - Fax:
Practice Address - Street 1:24962 OKAY RD
Practice Address - Street 2:
Practice Address - City:TECUMSEH
Practice Address - State:OK
Practice Address - Zip Code:74873-6504
Practice Address - Country:US
Practice Address - Phone:817-372-5098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-11
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist