Provider Demographics
NPI:1417061516
Name:JACKSON-SMITH, JILL L (DPM)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:L
Last Name:JACKSON-SMITH
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5711 E 71ST ST
Mailing Address - Street 2:SUITE 220
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-6628
Mailing Address - Country:US
Mailing Address - Phone:918-477-7096
Mailing Address - Fax:918-477-9362
Practice Address - Street 1:5711 E 71ST ST
Practice Address - Street 2:SUITE 115
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-6628
Practice Address - Country:US
Practice Address - Phone:918-494-2902
Practice Address - Fax:918-494-2905
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK187213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKU50595Medicare UPIN
OK571698746Medicare ID - Type UnspecifiedMEDICARE NUMBER