Provider Demographics
NPI:1639932023
Name:JACKMAN, MICHAEL STEPHEN
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:STEPHEN
Last Name:JACKMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2165 COUNTY STREET 2973
Mailing Address - Street 2:
Mailing Address - City:BLANCHARD
Mailing Address - State:OK
Mailing Address - Zip Code:73010-3556
Mailing Address - Country:US
Mailing Address - Phone:405-446-0928
Mailing Address - Fax:
Practice Address - Street 1:2219 SW 74TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-3931
Practice Address - Country:US
Practice Address - Phone:405-355-3239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant