Basic Information
| Provider Information | |||||||||
| NPI: | 1144405937 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | KACI | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6600 S YALE AVE | ||||||||
| Address2: | SUITE 1400 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741363347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184886001 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10505 E 91ST ST | ||||||||
| Address2: | STE 208 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184948500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/31/2007 | ||||||||
| LastUpdateDate: | 09/18/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R0066985 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.