Provider Demographics
NPI:1497419840
Name:JACKSON, JORDAN
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
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 1:227 E 35TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-2509
Mailing Address - Country:US
Mailing Address - Phone:405-473-5108
Mailing Address - Fax:
Practice Address - Street 1:2801 N STATE ROAD 7
Practice Address - Street 2:
Practice Address - City:MARGATE
Practice Address - State:FL
Practice Address - Zip Code:33063-5727
Practice Address - Country:US
Practice Address - Phone:954-205-1826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-22
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program