Individual
KENDRICK JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
2501 NE 15TH ST, OKLAHOMA CITY, OK 73117-5224
(405) 706-4537
Mailing address
2501 NE 15TH ST, OKLAHOMA CITY, OK 73117-5224
(405) 706-4537
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200287120A
—
OK
Enumeration date
10/25/2012
Last updated
10/25/2012
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