| Doctor Name: | MRS. KIM MARIE JACKSON |
| NPI Number: | 1285933176 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | |
| License Number: | |
| Business Practice Address: | 2109 S Highway 69 Wagoner, OK - 744679310 |
| Business Phone Number: | 9184850242 |
| Business Fax Number: | 9184850204 |
| Mailing Address: | 2109 S Highway 69, WAGONER |
| State: | OK |
| Postal Code: | 744679310 |
| Phone Number: | 9184850242 |
| Fax Number: | 9184850204 |
| NPI Enumeration Date: | 03/18/2011 |
| NPI Last Update Date: | 03/18/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101Y00000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A provider who is trained and educated in the performance of behavior health services through interpersonal communications and analysis. Training and education at the specialty level usually requires a master |