Provider Demographics
NPI:1568021475
Name:JACKSON, BRIANNA L (OT)
Entity Type:Individual
Prefix:
First Name:BRIANNA
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 N HIGHTOWER ST
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521-2637
Mailing Address - Country:US
Mailing Address - Phone:402-826-0414
Mailing Address - Fax:
Practice Address - Street 1:1200 E PECAN ST
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-6192
Practice Address - Country:US
Practice Address - Phone:580-379-5820
Practice Address - Fax:580-379-5829
Is Sole Proprietor?:No
Enumeration Date:2019-06-13
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23818225X00000X
NE2309225X00000X
OK5335225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK201089720AMedicaid