Individual
STACEY JO JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
BHRS
Contact information
Practice address
17 S CENTRAL AVE, IDABEL, OK 74745-4625
(580) 306-0303
Mailing address
RR 3 BOX 421, BROKEN BOW, OK 74728-9204
(580) 306-0303
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
—
—
Other
Enumeration date
06/23/2011
Last updated
06/23/2011
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