Provider Demographics
NPI:1851604961
Name:BURRESS, JACKIE LYNNE (OD)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:LYNNE
Last Name:BURRESS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 N GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-7017
Mailing Address - Country:US
Mailing Address - Phone:918-456-5511
Mailing Address - Fax:
Practice Address - Street 1:1001 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-7017
Practice Address - Country:US
Practice Address - Phone:918-456-5511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-17
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2643152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist