Provider Demographics
NPI:1457594699
Name:JACKSON MEDICAL CLINIC, PC
Entity Type:Organization
Organization Name:JACKSON MEDICAL CLINIC, PC
Other - Org Name:JACKSON FAMILY CLINIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:NOEL
Authorized Official - Last Name:HALEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-485-5591
Mailing Address - Street 1:410 E CHEROKEE ST
Mailing Address - Street 2:
Mailing Address - City:WAGONER
Mailing Address - State:OK
Mailing Address - Zip Code:74467-4708
Mailing Address - Country:US
Mailing Address - Phone:918-485-5591
Mailing Address - Fax:918-485-5758
Practice Address - Street 1:410 E CHEROKEE ST
Practice Address - Street 2:
Practice Address - City:WAGONER
Practice Address - State:OK
Practice Address - Zip Code:74467-4708
Practice Address - Country:US
Practice Address - Phone:918-485-5591
Practice Address - Fax:918-485-5758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-17
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK28153208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100141080EMedicaid
OK100141080EMedicaid
OK450705149Medicare PIN