Provider Demographics
NPI:1790155042
Name:JACKSON, NICOLE DEXTER (OTA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:DEXTER
Last Name:JACKSON
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:JEAN
Other - Last Name:DEXTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14930 E 97TH ST N
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-4814
Mailing Address - Country:US
Mailing Address - Phone:918-595-0440
Mailing Address - Fax:
Practice Address - Street 1:3001 W BLUE STARR DR
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-2544
Practice Address - Country:US
Practice Address - Phone:918-342-5432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-29
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK614224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant