Provider Demographics
NPI:1275272890
Name:JACKSON, MADYSON NOELLE
Entity type:Individual
Prefix:
First Name:MADYSON
Middle Name:NOELLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MADYSON
Other - Middle Name:NOELLE
Other - Last Name:CRAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CM II
Mailing Address - Street 1:11700 S. PINE STREET
Mailing Address - Street 2:
Mailing Address - City:GUTHRIE
Mailing Address - State:OK
Mailing Address - Zip Code:73044
Mailing Address - Country:US
Mailing Address - Phone:580-302-3300
Mailing Address - Fax:
Practice Address - Street 1:4130 N LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73105
Practice Address - Country:US
Practice Address - Phone:054-267-3214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-01
Last Update Date:2025-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK316791171M00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator