Doctor Name: | VIVIAN JACKSON |
NPI Number: | 1164804563 |
Entity Type Code: | Individual (1) |
Gender: | F |
Credentials: | |
License Number: | |
Business Practice Address: | 800 S Greathouse Dr Atoka, OK - 745253431 |
Business Phone Number: | 5808892424 |
Business Fax Number: | 5808894050 |
Mailing Address: | Po Box 720, ATOKA |
State: | OK |
Postal Code: | 745250720 |
Phone Number: | |
Fax Number: | |
NPI Enumeration Date: | 06/22/2015 |
NPI Last Update Date: | 06/22/2015 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 390200000X |
License Number: | |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | |
Taxonomy Type: | Student, Health Care |
Taxonomy Classification: | Student in an Organized Health Care Education/Training Program |
Taxonomy Specialization: | |
Taxonomy Definition: | An individual who is enrolled in an organized health care education/training program leading to a degree, certification, registration, and/or licensure to provide health care. |