Ingrid W. Jackson, M.D., LLC

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

License

15786 Issued in OK

Legal business name

INGRID W. JACKSON, M.D., LLC

Doing business as

Faith Family Healthcare Clinic

Practice address

740 Signal Ridge Dr
Edmond, OK 73013-3675

Phone

(405) 418-0125

Fax

(405) 216-3454

NPI assigned

Feb 16, 2018

Last updated

Oct 28, 2024By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Tina White

Title

Owner

Phone

(405) 418-0125

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Faith Family Healthcare Clinic Doing business as

Locations

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Genevieve Dulan, M.D.

  • Family Medicine Physician
  • Oklahoma City, OK
  • NPI 1033391370
  NPD (past)
• Amy Musick

  • Nurse Practitioner
  • Moore, OK
  • NPI 1730642455
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1518739200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1730073600000",
    "number": "1205336187",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "740 SIGNAL RIDGE DR",
            "city": "EDMOND",
            "state": "OK",
            "postal_code": "730133675",
            "telephone_number": "405-418-0125",
            "fax_number": "405-216-3454"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "740 SIGNAL RIDGE DR",
            "city": "EDMOND",
            "state": "OK",
            "postal_code": "730133675",
            "telephone_number": "405-418-0125",
            "fax_number": "405-216-3454"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "INGRID W. JACKSON, M.D., LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-02-16",
        "last_updated": "2024-10-28",
        "certification_date": "2024-10-28",
        "status": "A",
        "authorized_official_last_name": "WHITE",
        "authorized_official_first_name": "TINA",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "405-418-0125"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "OK",
            "license": "15786",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100220060",
            "state": "OK"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Faith Family Healthcare Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Family Medicine Physician in Edmond, OK
• Providers in Edmond, OK by specialty
• Family Medicine Physician in Oklahoma

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 28, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.