Provider Demographics
NPI:1134448913
Name:JACKSON, GLENN ALLEN II
Entity type:Individual
Prefix:MR
First Name:GLENN
Middle Name:ALLEN
Last Name:JACKSON
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6736 S PEORIA AVE APT 221
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3649
Mailing Address - Country:US
Mailing Address - Phone:918-402-9235
Mailing Address - Fax:
Practice Address - Street 1:6736 S PEORIA AVE APT 221
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-3649
Practice Address - Country:US
Practice Address - Phone:918-402-9235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-19
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator