Provider Demographics
NPI:1164818993
Name:JACKSON, THERESA (MD)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4629 E 13TH PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74112-6103
Mailing Address - Country:US
Mailing Address - Phone:405-822-8297
Mailing Address - Fax:
Practice Address - Street 1:4629 E 13TH PL
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74112-6103
Practice Address - Country:US
Practice Address - Phone:405-822-8297
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-08
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10052439208600000X
OK32423207P00000X
OK1164818993390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program