Provider Demographics
NPI:1649622010
Name:JACKSON, VICKI LYN
Entity type:Individual
Prefix:MRS
First Name:VICKI
Middle Name:LYN
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 1:26496 255TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:SHADY POINT
Mailing Address - State:OK
Mailing Address - Zip Code:74956
Mailing Address - Country:US
Mailing Address - Phone:918-721-6515
Mailing Address - Fax:
Practice Address - Street 1:26496 255TH AVE
Practice Address - Street 2:
Practice Address - City:SHADY POINT
Practice Address - State:OK
Practice Address - Zip Code:74956-2011
Practice Address - Country:US
Practice Address - Phone:918-721-6515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-08
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator