Provider Demographics
NPI:1932931409
Name:JACKSON-BISHOP, EMMANUEL
Entity type:Individual
Prefix:MR
First Name:EMMANUEL
Middle Name:
Last Name:JACKSON-BISHOP
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:OKMULGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74447-4018
Mailing Address - Country:US
Mailing Address - Phone:918-636-4212
Mailing Address - Fax:
Practice Address - Street 1:417 EAST 3RD STREET
Practice Address - Street 2:
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447
Practice Address - Country:US
Practice Address - Phone:918-636-4212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-14
Last Update Date:2025-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK321122171M00000X
OKTBD106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst