Provider Demographics
NPI:1750095980
Name:JACKSON, SCOTTY (FNP-BC)
Entity type:Individual
Prefix:
First Name:SCOTTY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34550 AIRLINE RD
Mailing Address - Street 2:
Mailing Address - City:PAULS VALLEY
Mailing Address - State:OK
Mailing Address - Zip Code:73075-9337
Mailing Address - Country:US
Mailing Address - Phone:405-207-9238
Mailing Address - Fax:405-207-9240
Practice Address - Street 1:34550 AIRLINE RD
Practice Address - Street 2:
Practice Address - City:PAULS VALLEY
Practice Address - State:OK
Practice Address - Zip Code:73075-9337
Practice Address - Country:US
Practice Address - Phone:405-207-9238
Practice Address - Fax:405-207-9240
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-11
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0078720363LF0000X
OK211329363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily