Provider Demographics
NPI:1902263270
Name:JACKSON, CARL (PA-C)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22096 S 445TH EAST AVE
Mailing Address - Street 2:
Mailing Address - City:PORTER
Mailing Address - State:OK
Mailing Address - Zip Code:74454-3239
Mailing Address - Country:US
Mailing Address - Phone:918-625-7927
Mailing Address - Fax:
Practice Address - Street 1:8801 S 101ST EAST AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-5716
Practice Address - Country:US
Practice Address - Phone:918-579-6090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-18
Last Update Date:2016-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA 2616363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant