| Ingrid W. Jackson, M.d., Llc | |
|
740 Signal Ridge Dr Edmond OK 73013-3675 | |
| (405) 418-0125 | |
| (405) 216-3454 |
| Full Name | Ingrid W. Jackson, M.d., Llc |
|---|---|
| Speciality | Family Medicine |
| Location | 740 Signal Ridge Dr, Edmond, Oklahoma |
| Authorized Official Name and Position | Tina White (OWNER) |
| Authorized Official Contact | 4054180125 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Ingrid W. Jackson, M.d., Llc 740 Signal Ridge Dr Edmond OK 73013-3675 Ph: (405) 418-0125 | Ingrid W. Jackson, M.d., Llc 740 Signal Ridge Dr Edmond OK 73013-3675 Ph: (405) 418-0125 |
| NPI Number | 1205336187 |
|---|---|
| Provider Enumeration Date | 02/16/2018 |
| Last Update Date | 10/28/2024 |
| Medicare PECOS PAC ID | 9335493543 |
|---|---|
| Medicare Enrollment ID | O20181106002640 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1205336187 | NPI | - | NPPES |
| 100220060 | Medicaid | OK |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | 15786 (Oklahoma) | Primary |
| Provider Name | Ingrid W Jackson |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1265492417 PECOS PAC ID: 2062580053 Enrollment ID: I20081003000393 |
| Provider Name | Terrence Lakin |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1083682140 PECOS PAC ID: 1355512138 Enrollment ID: I20220718001808 |
| Provider Name | Karisa Jo Kennedy |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1053623728 PECOS PAC ID: 1850764945 Enrollment ID: I20230311000227 |
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