Provider Demographics
NPI:1528598463
Name:JACKSON, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
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 1:3720 SILVER OAK CT
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74107-4050
Mailing Address - Country:US
Mailing Address - Phone:918-521-7053
Mailing Address - Fax:
Practice Address - Street 1:1401 CHARLES PAGE BLVD
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74127-8820
Practice Address - Country:US
Practice Address - Phone:918-521-7053
Practice Address - Fax:918-516-0233
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-14
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health