Champlain, Wallace Jackson

Champlain, Wallace Jackson is an individual health care provider with primary practice located at 1500 E Downing St Ste 208 , Tahlequah OK 74464-3234. He recently has only one registered license in Allopathic & Osteopathic Physicians / Obstetrics & Gynecology, which is considered as his primary health care specialty. Champlain, Wallace Jackson can be contacted via phone (918) 456-2496.

Contact Information

Primary practice address
1500 E Downing St Ste 208 Tahlequah OK 74464-3234
Phone: (918) 456-2496
Fax: (918) 456-7108
Website:
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Health care specialties

SpecialtyCodeLicense #State
Allopathic & Osteopathic Physicians / Obstetrics & Gynecology 207V00000X 1994 Oklahoma

Profile Details

NPI number 1689648636
LBN Legal business name Champlain, Wallace Jackson
Credentials Doctor of Osteopathy (DO)
Entity Individual
Sole proprietor 1 No
Enumeration date Feb 15th, 2006
Last updated Jun 4th, 2019 - about 5 years ago

1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.

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Identifiers

StateTypeNumberIssuer
All States NPI 1689648636 NPPES
Oklahoma MEDICAID 100118860A

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