Provider Demographics
NPI:1417788241
Name:JACKSON, BREANNE (APRN)
Entity type:Individual
Prefix:
First Name:BREANNE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:STROUD
Mailing Address - State:OK
Mailing Address - Zip Code:74079-3627
Mailing Address - Country:US
Mailing Address - Phone:405-915-4726
Mailing Address - Fax:
Practice Address - Street 1:1602 HIGHWAY 9 E
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:OK
Practice Address - Zip Code:74868-6618
Practice Address - Country:US
Practice Address - Phone:405-716-9077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-13
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK219744363LF0000X
OK2197444363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily