Provider Demographics
NPI:1659241511
Name:JACKSON, KATHRYN
Entity type:Individual
Prefix:
First Name:KATHRYN
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 1:10710 N 121ST EAST AVE
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-5219
Mailing Address - Country:US
Mailing Address - Phone:918-857-5284
Mailing Address - Fax:
Practice Address - Street 1:10710 N 121ST EAST AVE
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-5219
Practice Address - Country:US
Practice Address - Phone:918-857-5284
Practice Address - Fax:918-857-5284
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-06
Last Update Date:2025-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5790225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist