Provider Demographics
NPI:1669433546
Name:JACKSON, JOHN CLAUDE (DO)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:CLAUDE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:DOUGLAS
Other - Last Name:GORMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
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
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-30
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1672207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100141080CMedicaid
OK100141080EMedicaid
OK100141080CMedicaid
OK$$$$$$$$$Medicare UPIN