Provider Demographics
NPI:1164847695
Name:JACKSON, MMELIKA
Entity Type:Individual
Prefix:
First Name:MMELIKA
Middle Name:
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 1:1201 CAVALIER ST
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-1821
Mailing Address - Country:US
Mailing Address - Phone:405-512-4212
Mailing Address - Fax:
Practice Address - Street 1:2401 NW 39TH ST
Practice Address - Street 2:STE. 103
Practice Address - City:OKLAHOMA
Practice Address - State:OK
Practice Address - Zip Code:73112
Practice Address - Country:US
Practice Address - Phone:405-512-4212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-20
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator