Provider Demographics
NPI:1891315222
Name:JACKSON, JORDAN TYLER (MEDICAL STUDENT)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:TYLER
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MEDICAL STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19512 CREST RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-3504
Mailing Address - Country:US
Mailing Address - Phone:918-367-8128
Mailing Address - Fax:
Practice Address - Street 1:19512 CREST RIDGE DR
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73012-3504
Practice Address - Country:US
Practice Address - Phone:918-367-8128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-27
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program