Provider Demographics
NPI:1720403256
Name:JACKSON, DENISE ANN (BSW)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:ANN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:DENISE
Other - Middle Name:ANN
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BSW
Mailing Address - Street 1:1003 N GRIFFIN AVE
Mailing Address - Street 2:
Mailing Address - City:OKMULGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74447-2512
Mailing Address - Country:US
Mailing Address - Phone:918-777-0625
Mailing Address - Fax:
Practice Address - Street 1:1003 N GRIFFIN AVE
Practice Address - Street 2:
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447-2512
Practice Address - Country:US
Practice Address - Phone:918-777-0625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-20
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker