Provider Demographics
NPI:1912396086
Name:JACKSON, LAUREN (PA-C)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6585 S YALE AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-8315
Mailing Address - Country:US
Mailing Address - Phone:918-481-2767
Mailing Address - Fax:918-494-9277
Practice Address - Street 1:6585 S YALE AVE STE 200
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-8315
Practice Address - Country:US
Practice Address - Phone:918-481-2767
Practice Address - Fax:918-494-9277
Is Sole Proprietor?:No
Enumeration Date:2015-01-13
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2490363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200572730AMedicaid