Provider Demographics
NPI:1962441170
Name:JACKSON, KIMETHRIA LAURIE (MSN, ARNP)
Entity Type:Individual
Prefix:
First Name:KIMETHRIA
Middle Name:LAURIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MSN, ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 ARLINGTON ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-4072
Mailing Address - Country:US
Mailing Address - Phone:580-436-1526
Mailing Address - Fax:580-436-1354
Practice Address - Street 1:1201 ARLINGTON ST
Practice Address - Street 2:SUITE B
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-4072
Practice Address - Country:US
Practice Address - Phone:580-436-1526
Practice Address - Fax:580-436-1354
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0046831363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily