Provider Demographics
NPI:1457034613
Name:JACKSON, NAOMI MARIE
Entity Type:Individual
Prefix:
First Name:NAOMI
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8714 NE 47TH ST
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:OK
Mailing Address - Zip Code:73084-2012
Mailing Address - Country:US
Mailing Address - Phone:405-227-4604
Mailing Address - Fax:
Practice Address - Street 1:8714 NE 47TH ST
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:OK
Practice Address - Zip Code:73084-2012
Practice Address - Country:US
Practice Address - Phone:405-227-4604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-14
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist