Provider Demographics
NPI:1457592156
Name:JACKSON, PATRICIA ELIZABETH
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:ELIZABETH
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:ELIZABETH
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1824 RIDGEWAY DR
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-5631
Mailing Address - Country:US
Mailing Address - Phone:405-626-2191
Mailing Address - Fax:
Practice Address - Street 1:5116 N PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-2077
Practice Address - Country:US
Practice Address - Phone:405-943-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-10
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist