Provider Demographics
NPI:1093181299
Name:SILVA DE JACKSON, ELSA
Entity Type:Individual
Prefix:
First Name:ELSA
Middle Name:
Last Name:SILVA DE 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 1:102 N DENVER AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74103-1806
Mailing Address - Country:US
Mailing Address - Phone:918-350-8574
Mailing Address - Fax:
Practice Address - Street 1:2001 S GARNETT RD
Practice Address - Street 2:SUITE G
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74128-1836
Practice Address - Country:US
Practice Address - Phone:918-878-7877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-11
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator