Provider Demographics
NPI:1205336187
Name:INGRID W. JACKSON, M.D., LLC
Entity type:Organization
Organization Name:INGRID W. JACKSON, M.D., LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-418-0125
Mailing Address - Street 1:740 SIGNAL RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-3675
Mailing Address - Country:US
Mailing Address - Phone:405-418-0125
Mailing Address - Fax:405-216-3454
Practice Address - Street 1:740 SIGNAL RIDGE DR
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-3675
Practice Address - Country:US
Practice Address - Phone:405-418-0125
Practice Address - Fax:405-216-3454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-16
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15786207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100220060Medicaid