Provider Demographics
NPI:1679395313
Name:JACKSON, KOREE MATHEW
Entity type:Individual
Prefix:
First Name:KOREE
Middle Name:MATHEW
Last Name:JACKSON
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 1:32426 S 554 LOOP
Mailing Address - Street 2:
Mailing Address - City:JAY
Mailing Address - State:OK
Mailing Address - Zip Code:74346
Mailing Address - Country:US
Mailing Address - Phone:417-680-4587
Mailing Address - Fax:
Practice Address - Street 1:32426 S 554 LOOP
Practice Address - Street 2:
Practice Address - City:JAY
Practice Address - State:OK
Practice Address - Zip Code:74346
Practice Address - Country:US
Practice Address - Phone:417-680-4587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-24
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKS084009464172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver