Provider Demographics
NPI:1760005664
Name:RODGERS, JACKSON (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:JACKSON
Middle Name:
Last Name:RODGERS
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5A WHISPERING PINES CT
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:IL
Mailing Address - Zip Code:62544-7218
Mailing Address - Country:US
Mailing Address - Phone:636-866-8958
Mailing Address - Fax:
Practice Address - Street 1:1000 N LEE AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73102-1036
Practice Address - Country:US
Practice Address - Phone:405-272-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-26
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X, 390200000X
OK4644363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty