Provider Demographics
NPI:1689118903
Name:JACKSON, TER-REE L
Entity Type:Individual
Prefix:DR
First Name:TER-REE
Middle Name:L
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 1:1308 WOODBRIAR LN
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110-8018
Mailing Address - Country:US
Mailing Address - Phone:405-610-2159
Mailing Address - Fax:
Practice Address - Street 1:1308 WOODBRIAR LN
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-8018
Practice Address - Country:US
Practice Address - Phone:405-610-2159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-05
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator