Provider Demographics
NPI:1457886871
Name:JACKSON, TAFT II
Entity Type:Individual
Prefix:
First Name:TAFT
Middle Name:
Last Name:JACKSON
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 NE 13TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73117-1022
Mailing Address - Country:US
Mailing Address - Phone:405-248-9368
Mailing Address - Fax:
Practice Address - Street 1:1200 NE 13TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73117-1022
Practice Address - Country:US
Practice Address - Phone:405-248-9368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-23
Last Update Date:2017-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician