Provider Demographics
NPI:1073887808
Name:JACKSON, KARIS LAVON SR
Entity Type:Individual
Prefix:MR
First Name:KARIS
Middle Name:LAVON
Last Name:JACKSON
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 S 182ND EAST AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74108-2133
Mailing Address - Country:US
Mailing Address - Phone:918-691-8579
Mailing Address - Fax:
Practice Address - Street 1:218 S 182ND EAST AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74108-2133
Practice Address - Country:US
Practice Address - Phone:918-691-8579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-24
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1194001412246ZE0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic