Provider Demographics
NPI:1083339022
Name:JACKSON, JULIA ANNE (APRN)
Entity Type:Individual
Prefix:
First Name:JULIA
Middle Name:ANNE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1422 E 71ST ST STE B
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-5060
Mailing Address - Country:US
Mailing Address - Phone:918-710-0422
Mailing Address - Fax:918-949-6681
Practice Address - Street 1:1422 E 71ST ST STE B
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-5060
Practice Address - Country:US
Practice Address - Phone:918-710-0422
Practice Address - Fax:918-949-6681
Is Sole Proprietor?:No
Enumeration Date:2022-10-11
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK205727364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK205727OtherAPRN- CNS