Provider Demographics
NPI:1013771161
Name:JACKSON, KYLEE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:KYLEE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1294
Mailing Address - Street 2:
Mailing Address - City:INOLA
Mailing Address - State:OK
Mailing Address - Zip Code:74036-1294
Mailing Address - Country:US
Mailing Address - Phone:918-693-8393
Mailing Address - Fax:
Practice Address - Street 1:4444 S HARVARD AVE STE 300
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2611
Practice Address - Country:US
Practice Address - Phone:918-992-6400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-09
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK216736363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily