Provider Demographics
NPI:1053159194
Name:JACKSON, KATHRYN ANDREA SHEREE'
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ANDREA SHEREE'
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14902 E SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74019-4434
Mailing Address - Country:US
Mailing Address - Phone:918-342-2635
Mailing Address - Fax:
Practice Address - Street 1:14902 E SCHOOL RD
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74019-4434
Practice Address - Country:US
Practice Address - Phone:918-341-3626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-15
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator