Provider Demographics
NPI:1336954569
Name:PHELPS, JACKSON DAVIS (LPN)
Entity type:Individual
Prefix:MR
First Name:JACKSON
Middle Name:DAVIS
Last Name:PHELPS
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:781 GRAND CASINO BLVD
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-1005
Mailing Address - Country:US
Mailing Address - Phone:405-964-5770
Mailing Address - Fax:405-695-6029
Practice Address - Street 1:781 GRAND CASINO BLVD
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-1005
Practice Address - Country:US
Practice Address - Phone:405-964-5770
Practice Address - Fax:405-695-6029
Is Sole Proprietor?:No
Enumeration Date:2025-02-13
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK219424164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse