Provider Demographics
NPI:1962701391
Name:JACKSON, DANA LYNN (LADC UNDER SUPER)
Entity type:Individual
Prefix:MRS
First Name:DANA
Middle Name:LYNN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LADC UNDER SUPER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2413 LARKHAVEN ST
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-4326
Mailing Address - Country:US
Mailing Address - Phone:405-310-6108
Mailing Address - Fax:
Practice Address - Street 1:2448 E. 81ST STREET
Practice Address - Street 2:SUITE 4824 / CITIPLEXTOWERS
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-1814
Practice Address - Country:US
Practice Address - Phone:918-486-9996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-24
Last Update Date:2011-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKP082039069Medicaid