Provider Demographics
NPI:1689943094
Name:JACKSON, JACQULINE
Entity Type:Individual
Prefix:
First Name:JACQULINE
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 1:33207 45TH ST
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-3423
Mailing Address - Country:US
Mailing Address - Phone:405-214-0116
Mailing Address - Fax:877-334-8552
Practice Address - Street 1:1127 N KICKAPOO AVE
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74801-4845
Practice Address - Country:US
Practice Address - Phone:405-214-0116
Practice Address - Fax:877-334-8552
Is Sole Proprietor?:No
Enumeration Date:2011-12-14
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5594101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional