Provider Demographics
NPI:1578847505
Name:JACKSON, JUDY ELLEN (MASTER OF SOCIAL WEL)
Entity Type:Individual
Prefix:MRS
First Name:JUDY
Middle Name:ELLEN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MASTER OF SOCIAL WEL
Other - Prefix:
Other - First Name:JUDY
Other - Middle Name:ELLEN
Other - Last Name:BARRETT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1950 N OKMULGEE
Mailing Address - Street 2:
Mailing Address - City:OKMULGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74447-6534
Mailing Address - Country:US
Mailing Address - Phone:918-756-7700
Mailing Address - Fax:918-756-3347
Practice Address - Street 1:1950 N OKMULGEE
Practice Address - Street 2:
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447-6534
Practice Address - Country:US
Practice Address - Phone:918-756-7700
Practice Address - Fax:918-756-3347
Is Sole Proprietor?:No
Enumeration Date:2011-10-10
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor