Provider Demographics
NPI:1427179761
Name:JACKSON, RACHELLE
Entity Type:Individual
Prefix:
First Name:RACHELLE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RACHELLE
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1213 LESLIE LN
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-4403
Mailing Address - Country:US
Mailing Address - Phone:405-412-0705
Mailing Address - Fax:
Practice Address - Street 1:1151 E MAIN ST
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-5331
Practice Address - Country:US
Practice Address - Phone:405-364-1420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist