Provider Demographics
NPI:1730476730
Name:JACKSON, JARED (MD)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1803
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73083-1803
Mailing Address - Country:US
Mailing Address - Phone:405-418-4800
Mailing Address - Fax:405-418-4820
Practice Address - Street 1:3431 S BOULEVARD STE 105
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-5514
Practice Address - Country:US
Practice Address - Phone:405-771-0880
Practice Address - Fax:405-562-2116
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-29
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK29168207W00000X, 261QM2500X
IN11016020A390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200752480AMedicaid