Active NPI
Koree Mathew Jackson
- Driver
- Jay, OK
National Provider Identifier
1679395313
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Driver
- License
- S084009464
- Practice address
- 32426 S 554 Loop
Jay, OK 74346 - Phone
- (417) 680-4587
- NPI assigned
- Oct 24, 2024
- Last updated
- Oct 24, 2024
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Driver | 172A00000X | S084009464 | OK | Primary |
Addresses
Primary practice location
32426 S 554 Loop
Jay, OK 74346
Mailing address
32426 S 554 Loop
Jay, OK 74346
Phone (417) 680-4587
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| S084009464 | OK | MD | Driver |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1729728000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1729728000000",
"number": "1679395313",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "32426 S 554 LOOP",
"city": "JAY",
"state": "OK",
"postal_code": "74346",
"telephone_number": "417-680-4587"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "32426 S 554 LOOP",
"city": "JAY",
"state": "OK",
"postal_code": "74346",
"telephone_number": "417-680-4587"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACKSON",
"first_name": "KOREE",
"middle_name": "MATHEW",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2024-10-24",
"last_updated": "2024-10-24",
"certification_date": "2024-10-22",
"status": "A"
},
"taxonomies": [
{
"code": "172A00000X",
"taxonomy_group": "",
"desc": "Driver",
"state": "OK",
"license": "S084009464",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Jay, OK
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 24, 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.