Provider Demographics
NPI:1700046943
Name:JACKSON, CAMILLE CATHERINE (MD)
Entity Type:Individual
Prefix:
First Name:CAMILLE
Middle Name:CATHERINE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CAMILLE
Other - Middle Name:CATHERINE
Other - Last Name:GUNDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4401 MCAULEY BLVD STE 2200
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-8561
Mailing Address - Country:US
Mailing Address - Phone:405-749-7023
Mailing Address - Fax:405-749-7025
Practice Address - Street 1:4401 MCAULEY BLVD STE 2200
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-8561
Practice Address - Country:US
Practice Address - Phone:405-749-7023
Practice Address - Fax:405-749-7025
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-11
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK28930207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Multi-Specialty