Provider Demographics
NPI:1417254681
Name:JACKSON, COMELIA (MS)
Entity Type:Individual
Prefix:MRS
First Name:COMELIA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8616 NE 35TH ST
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:OK
Mailing Address - Zip Code:73084-3206
Mailing Address - Country:US
Mailing Address - Phone:405-532-7815
Mailing Address - Fax:
Practice Address - Street 1:8616 NE 35TH ST
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:OK
Practice Address - Zip Code:73084-3206
Practice Address - Country:US
Practice Address - Phone:405-532-7815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-23
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)