Provider Demographics
NPI:1770234452
Name:JACKSON, MICHAEL PAUL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PAUL
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 S LINWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:CUSHING
Mailing Address - State:OK
Mailing Address - Zip Code:74023-4210
Mailing Address - Country:US
Mailing Address - Phone:918-510-8190
Mailing Address - Fax:
Practice Address - Street 1:1624 CIMARRON PLZ
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74075-3467
Practice Address - Country:US
Practice Address - Phone:405-372-2202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-13
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist