Jackson Medical Clinic, PC

Primary specialty

General Practice PhysicianTaxonomy code 208D00000X

License

28153 Issued in OK

Legal business name

JACKSON MEDICAL CLINIC, PC

Practice address

410 E Cherokee St
Wagoner, OK 74467-4708

Phone

(918) 485-5591

Fax

(918) 485-5758

NPI assigned

Apr 17, 2009

Organization subpart

No

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

Authorized official

Name

Kelly Noel Haley

Title

Office Manager

Phone

(918) 485-5591

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• JACKSON FAMILY CLINIC Former legal business name

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Chriss B Roberts, D.O.

  • Family Medicine Physician
  • Wagoner, OK
  • NPI 1710979315
  NPD (past)

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

{
    "created_epoch": "1239926400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1490140800000",
    "number": "1457594699",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "410 E CHEROKEE ST",
            "city": "WAGONER",
            "state": "OK",
            "postal_code": "744674708",
            "telephone_number": "918-485-5591",
            "fax_number": "918-485-5758"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "410 E CHEROKEE ST",
            "city": "WAGONER",
            "state": "OK",
            "postal_code": "744674708",
            "telephone_number": "918-485-5591",
            "fax_number": "918-485-5758"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "JACKSON MEDICAL CLINIC, PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-04-17",
        "last_updated": "2017-03-22",
        "status": "A",
        "authorized_official_last_name": "HALEY",
        "authorized_official_first_name": "KELLY",
        "authorized_official_middle_name": "NOEL",
        "authorized_official_title_or_position": "OFFICE MANAGER",
        "authorized_official_telephone_number": "918-485-5591"
    },
    "taxonomies": [
        {
            "code": "208D00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "General Practice",
            "state": "OK",
            "license": "28153",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100141080E",
            "state": "OK"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "JACKSON FAMILY CLINIC",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

• Jill Huckaby
• Jordan Hurst
• Michael Dean Hutchings
• Kyla Nicole Ibarra, PTA
• J & a Family Medicine, LLC
• John Claude Jackson, D.O.
• Kim Marie Jackson
• Maeghan Lee Jakubovitz
• Teresa Melinda James, APRN CFNP
• Jeff S. Jennings, DO, PLLC

• General Practice Physician in Wagoner, OK
• Providers in Wagoner, OK by specialty
• General Practice Physician in Oklahoma

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 22, 2017; 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.