Provider Demographics
NPI:1588007595
Name:JACKSON, SA'RITA CHERAN
Entity Type:Individual
Prefix:
First Name:SA'RITA
Middle Name:CHERAN
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 1:4600 WOODLAND PARK TER
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:OK
Mailing Address - Zip Code:73084-2738
Mailing Address - Country:US
Mailing Address - Phone:405-201-1604
Mailing Address - Fax:
Practice Address - Street 1:1404 NE 14TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73117-2021
Practice Address - Country:US
Practice Address - Phone:405-201-1604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-09
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200287120AMedicaid