Provider Demographics
NPI:1639700214
Name:JACKSON, TOHNYONAH
Entity Type:Individual
Prefix:
First Name:TOHNYONAH
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 1:7500 KNIGHT LAKE DR APT 123
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73132-6019
Mailing Address - Country:US
Mailing Address - Phone:405-339-6369
Mailing Address - Fax:
Practice Address - Street 1:7500 KNIGHT LAKE DR APT 123
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73132-6019
Practice Address - Country:US
Practice Address - Phone:405-339-6369
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-31
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor