Provider Demographics
NPI:1205311396
Name:JACKSON-HEATH, CARMEN
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:
Last Name:JACKSON-HEATH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3030 NW EXPRESSWAY STE 809
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-5466
Mailing Address - Country:US
Mailing Address - Phone:405-917-7160
Mailing Address - Fax:405-917-7161
Practice Address - Street 1:3030 NW EXPRESSWAY STE 809
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-5466
Practice Address - Country:US
Practice Address - Phone:405-917-7160
Practice Address - Fax:405-917-7161
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-25
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOKSTATEOtherSLP