Individual
ANTHONY JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
1015 WATERWOOD PKWY, EDMOND, OK 73034-5327
(405) 884-8085
Mailing address
PO BOX 18883, OKLAHOMA CITY, OK 73154-0883
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
101Y00000X
—
OK
Enumeration date
06/17/2014
Last updated
06/17/2014
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