Provider Demographics
NPI:1477197267
Name:JACKSON, CORTNEY
Entity Type:Individual
Prefix:
First Name:CORTNEY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SIOC 1624 CIMARRON PLAZA
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74075-3467
Mailing Address - Country:US
Mailing Address - Phone:405-338-7072
Mailing Address - Fax:
Practice Address - Street 1:SIOC 1624 CIMARRON PLAZA
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74075-3467
Practice Address - Country:US
Practice Address - Phone:405-338-7072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-05
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKK082948200175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist