Provider Demographics
NPI:1417203761
Name:JACKSON, JAMES RYAN
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:RYAN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 N DENMARK AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67212-3036
Mailing Address - Country:US
Mailing Address - Phone:316-641-3039
Mailing Address - Fax:
Practice Address - Street 1:4911 N PORTLAND AVE STE 111
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-6170
Practice Address - Country:US
Practice Address - Phone:316-641-3039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-24
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist