Provider Demographics
NPI:1417171554
Name:JACKSON, SHERRY ANN (RD)
Entity Type:Individual
Prefix:MRS
First Name:SHERRY
Middle Name:ANN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:399180 W 2700 RD
Mailing Address - Street 2:
Mailing Address - City:RAMONA
Mailing Address - State:OK
Mailing Address - Zip Code:74061-3530
Mailing Address - Country:US
Mailing Address - Phone:918-333-0598
Mailing Address - Fax:
Practice Address - Street 1:3500 E FRANK PHILLIPS BLVD
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74006-2411
Practice Address - Country:US
Practice Address - Phone:918-331-1776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKLD 73133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered