Provider Demographics
NPI:1801992243
Name:JACKSON, DARRYL W (DO)
Entity type:Individual
Prefix:DR
First Name:DARRYL
Middle Name:W
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:1322 KLABZUBA AVE
Mailing Address - Street 2:
Mailing Address - City:PRAGUE
Mailing Address - State:OK
Mailing Address - Zip Code:74864-4707
Mailing Address - Country:US
Mailing Address - Phone:405-567-2295
Mailing Address - Fax:405-567-4905
Practice Address - Street 1:1322 KLABZUBA ST
Practice Address - Street 2:
Practice Address - City:PRAGUE
Practice Address - State:OK
Practice Address - Zip Code:74864-4707
Practice Address - Country:US
Practice Address - Phone:405-567-2295
Practice Address - Fax:405-567-4905
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2010-08-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OK4354207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine