Provider Demographics
NPI:1275311706
Name:JACKSON, CHERYL LYNN
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:LYNN
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 1:7901 NE 10TH ST STE A209
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110-3689
Mailing Address - Country:US
Mailing Address - Phone:405-922-1565
Mailing Address - Fax:
Practice Address - Street 1:7901 NE 10TH ST STE A209
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-3689
Practice Address - Country:US
Practice Address - Phone:405-922-1565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist