Provider Demographics
NPI:1679512784
Name:JACKSON, TANYA KAYE (DPT)
Entity Type:Individual
Prefix:MRS
First Name:TANYA
Middle Name:KAYE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2488 E 81ST ST STE 290
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-4265
Mailing Address - Country:US
Mailing Address - Phone:918-927-3737
Mailing Address - Fax:918-927-3193
Practice Address - Street 1:12800 S MEMORIAL DR STE D
Practice Address - Street 2:
Practice Address - City:BIXBY
Practice Address - State:OK
Practice Address - Zip Code:74008-2577
Practice Address - Country:US
Practice Address - Phone:918-394-2770
Practice Address - Fax:918-394-2772
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3107225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200239070AMedicaid