# JACKSON MEDICAL CLINIC, PC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** JACKSON FAMILY CLINIC
- **Organization subpart:** No

## Provider details

- **NPI number:** 1457594699
- **Authorized official:** KELLY NOEL HALEY (OFFICE MANAGER)
- **Authorized official phone:** (918) 485-5591

## Contact information

- **Practice address:** 410 E CHEROKEE ST, WAGONER, OK 74467-4708
- **Practice address phone:** (918) 485-5591
- **Practice address fax:** (918) 485-5758
- **Mailing address:** 410 E CHEROKEE ST, WAGONER, OK 74467-4708
- **Mailing address phone:** (918) 485-5591
- **Mailing address fax:** (918) 485-5758

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 208D00000X | General Practice Physician | 28153 | OK | Yes |

## Other

- **Enumeration date:** 04/17/2009
- **Last updated:** 03/22/2017

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 100141080E | — | OK |