Provider Demographics
NPI:1396970976
Name:INGRID W JACKSON MD INC. P.C.
Entity type:Organization
Organization Name:INGRID W JACKSON MD INC. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:INGRID
Authorized Official - Middle Name:WORRELL
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-473-7927
Mailing Address - Street 1:6957 NW EXPRESSWAY # 254
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73132-3533
Mailing Address - Country:US
Mailing Address - Phone:405-473-7927
Mailing Address - Fax:405-470-7712
Practice Address - Street 1:13321 N MERIDIAN AVE
Practice Address - Street 2:STE 314
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-8356
Practice Address - Country:US
Practice Address - Phone:405-470-7189
Practice Address - Fax:405-470-7712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-26
Last Update Date:2009-05-26
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
OK100220060BMedicaid
OKE37081Medicare UPIN
OK100220060BMedicaid