Provider Demographics
NPI:1699045104
Name:JACKSON, TERA
Entity Type:Individual
Prefix:MRS
First Name:TERA
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 1:1512 PATRICIA DR
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73130-1637
Mailing Address - Country:US
Mailing Address - Phone:405-812-4692
Mailing Address - Fax:
Practice Address - Street 1:1717 W 33RD ST
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-3863
Practice Address - Country:US
Practice Address - Phone:405-216-5608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-01
Last Update Date:2012-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst