Provider Demographics
NPI:1306140876
Name:JACKSON, ANDREA BESSIE
Entity type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:BESSIE
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 1:6030 S MAY AVE APT 451
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73159-1410
Mailing Address - Country:US
Mailing Address - Phone:405-684-9976
Mailing Address - Fax:
Practice Address - Street 1:6030 S MAY AVE APT 451
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-1410
Practice Address - Country:US
Practice Address - Phone:405-684-9976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-27
Last Update Date:2010-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator