Provider Demographics
NPI:1104674241
Name:JACKSON, DONNA MAY (MS RD/LD)
Entity type:Individual
Prefix:MRS
First Name:DONNA
Middle Name:MAY
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS RD/LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 MEDICAL PKWY
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74017-1082
Mailing Address - Country:US
Mailing Address - Phone:918-679-8911
Mailing Address - Fax:
Practice Address - Street 1:3000 MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-1082
Practice Address - Country:US
Practice Address - Phone:918-679-8911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-13
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1082133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered