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Individual

CORIE L JACKSON

Active
Sole proprietor
No

Provider details

NPI number
Gender
F

Contact information

Practice address
2225 N UNION ST, PONCA CITY, OK 74601-1555
(918) 308-5515
(580) 215-5765
Mailing address
2225 N UNION ST, PONCA CITY, OK 74601-1555
(918) 308-5515
(580) 215-5765

Taxonomy

Speciality
Code
Description
License number
State
175T00000X
Peer Specialist
Primary
G083070519
OK

Other

Enumeration date
02/06/2021
Last updated
03/09/2021
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