Individual
BRENT JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
2377 COUNTY ROAD 1201, TUTTLE, OK 73089-1067
(405) 412-3213
Mailing address
2377 COUNTY ROAD 1201, TUTTLE, OK 73089-1067
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
96391
OK
363LA2100X
Acute Care Nurse Practitioner
Primary
210172
OK
Other
Enumeration date
08/06/2022
Last updated
09/04/2022
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