Provider Demographics
NPI:1285056887
Name:JACKSON, MALARIE
Entity type:Individual
Prefix:
First Name:MALARIE
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 1:609 W. MEMORIAL RD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73114
Mailing Address - Country:US
Mailing Address - Phone:405-418-5400
Mailing Address - Fax:
Practice Address - Street 1:609 W. MEMORIAL RD.
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73114
Practice Address - Country:US
Practice Address - Phone:405-418-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-16
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK98159363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily