Provider Demographics
NPI:1558858068
Name:JAMES JACKSON, MD LLC
Entity Type:Organization
Organization Name:JAMES JACKSON, MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:TAWANA
Authorized Official - Middle Name:
Authorized Official - Last Name:HILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-896-7901
Mailing Address - Street 1:13924 QUAIL POINTE DR STE B
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1024
Mailing Address - Country:US
Mailing Address - Phone:405-896-7901
Mailing Address - Fax:405-242-4074
Practice Address - Street 1:3330 NW 56TH ST STE 612
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4470
Practice Address - Country:US
Practice Address - Phone:405-610-8810
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-19
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK27258261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK2019800000XMedicaid
OK202K00000XMedicaid