Individual
JARED JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
3431 S BOULEVARD STE 105, EDMOND, OK 73013-5514
(405) 771-0880
(405) 562-2116
Mailing address
PO BOX 1803, EDMOND, OK 73083-1803
(405) 418-4800
(405) 418-4820
Taxonomy
Speciality
Code
Description
License number
State
207W00000X
Ophthalmology Physician
Primary
29168
OK
261QM2500X
Medical Specialty Clinic/Center
29168
OK
390200000X
Student in an Organized Health Care Education/Training Program
11016020A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200752480A
—
OK
Enumeration date
06/29/2011
Last updated
04/21/2020
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