Individual
CARL JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
8801 S 101ST EAST AVE, TULSA, OK 74133-5716
(918) 579-6090
Mailing address
22096 S 445TH EAST AVE, PORTER, OK 74454-3239
(918) 625-7927
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA 2616
OK
Other
Enumeration date
01/18/2016
Last updated
01/18/2016
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