Provider Demographics
NPI:1679826747
Name:JACKSON, KENDRICK
Entity Type:Individual
Prefix:
First Name:KENDRICK
Middle Name:
Last Name:JACKSON
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 1:2501 NE 15TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73117-5224
Mailing Address - Country:US
Mailing Address - Phone:405-706-4537
Mailing Address - Fax:
Practice Address - Street 1:2501 NE 15TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73117-5224
Practice Address - Country:US
Practice Address - Phone:405-706-4537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-25
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200287120AMedicaid