Organization
JACKSON MEDICAL CLINIC, PC
Active
Other names
JACKSON FAMILY CLINIC
Organization subpart
No
Provider details
NPI number
Authorized official
KELLY NOEL HALEY (OFFICE MANAGER)
(918) 485-5591
Entity
Organization
Contact information
Practice address
410 E CHEROKEE ST, WAGONER, OK 74467-4708
(918) 485-5591
(918) 485-5758
Mailing address
410 E CHEROKEE ST, WAGONER, OK 74467-4708
(918) 485-5591
(918) 485-5758
Taxonomy
Speciality
Code
Description
License number
State
208D00000X
General Practice Physician
Primary
28153
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100141080E
—
OK
Enumeration date
04/17/2009
Last updated
03/22/2017
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