Provider Demographics
NPI:1215278031
Name:JACKSON, SHAKERA
Entity type:Individual
Prefix:MRS
First Name:SHAKERA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1332 NE 5TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73117-2440
Mailing Address - Country:US
Mailing Address - Phone:405-602-9519
Mailing Address - Fax:
Practice Address - Street 1:1915 N MARTIN LUTHER KING AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73111-1405
Practice Address - Country:US
Practice Address - Phone:405-470-9355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-04
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health