Provider Demographics
NPI:1265492417
Name:JACKSON, INGRID WORRELL (MD)
Entity Type:Individual
Prefix:MRS
First Name:INGRID
Middle Name:WORRELL
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5720 W MEMORIAL RD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73142-2010
Mailing Address - Country:US
Mailing Address - Phone:405-470-4700
Mailing Address - Fax:405-470-7112
Practice Address - Street 1:5720 W MEMORIAL RD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73142-2010
Practice Address - Country:US
Practice Address - Phone:405-470-4700
Practice Address - Fax:405-470-7112
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15786207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100220060DMedicaid
OK248318101Medicare PIN
OKOK401154Medicare PIN