Provider Demographics
NPI:1457491037
Name:JACKSON, KENNETH C (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:C
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7301 N COMANCHE AVE
Mailing Address - Street 2:
Mailing Address - City:WARR ACRES
Mailing Address - State:OK
Mailing Address - Zip Code:73132-6646
Mailing Address - Country:US
Mailing Address - Phone:405-721-8090
Mailing Address - Fax:405-722-8529
Practice Address - Street 1:7301 N COMANCHE AVE
Practice Address - Street 2:OU PHYSICIANS
Practice Address - City:WARR ACRES
Practice Address - State:OK
Practice Address - Zip Code:73132-6646
Practice Address - Country:US
Practice Address - Phone:405-721-8090
Practice Address - Fax:405-722-8529
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11030174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK11030OtherLICENSE
OK11030OtherLICENSE
OK11030OtherLICENSE