Provider Demographics
NPI:1134629405
Name:JACKSON, JACOB (APRN, CNP)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:APRN, CNP
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 2339
Mailing Address - Street 2:
Mailing Address - City:ELK CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73648-2339
Mailing Address - Country:US
Mailing Address - Phone:580-225-2518
Mailing Address - Fax:580-225-3167
Practice Address - Street 1:1800 W 1ST ST STE 105B
Practice Address - Street 2:
Practice Address - City:ELK CITY
Practice Address - State:OK
Practice Address - Zip Code:73644-3133
Practice Address - Country:US
Practice Address - Phone:580-225-2518
Practice Address - Fax:580-225-3167
Is Sole Proprietor?:No
Enumeration Date:2018-02-13
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK113330363LF0000X, 163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical