Provider Demographics
NPI:1891918454
Name:JACKSON, PAMALA DEE (PT)
Entity Type:Individual
Prefix:
First Name:PAMALA
Middle Name:DEE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:PAMALA
Other - Middle Name:DEE
Other - Last Name:FULLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14617 BROADWAY CIR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73170-7221
Mailing Address - Country:US
Mailing Address - Phone:405-200-2355
Mailing Address - Fax:
Practice Address - Street 1:6400 N SANTA FE AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-9126
Practice Address - Country:US
Practice Address - Phone:405-840-2903
Practice Address - Fax:405-840-3256
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2129225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist