BRENT JACKSON — NPI 1245967405 (Licensed & Credentialed Physician Assistants & Advanced Practice Nursing Providers — Nurse Practitioner, Acute Care in TUTTLE, OK)

CMS-1500 Box 24J / 33a • NPI

1245967405

Type 1 Individual Rendering/Ordering

HIPAA NUCC Taxonomy • CMS Code

363LA2100X (CMS 50)

Licensed & Credentialed Physician Assistants & Advanced Practice Nursing Providers — Nurse Practitioner, Acute Care

Box 32 Service Location & ZIP+4

2377 COUNTY ROAD 1201, TUTTLE, OK, 73089-1067

✓ 9-Digit EDI 837 ZIP+4 (73089-1067)

Practice Phone & Referral Fax

(405) 412-3213

Direct NPPES Verification Line

✓ HHS OIG LEIE Sanction Screening — VERIFIED CLEAR: NPI 1245967405 (BRENT JACKSON) has 0 active federal exclusions across all 84,224 HHS OIG LEIE sanction records (Database Verified: 2026-11-11).

CMS Medicare Order & Referring PECOS Eligibility

This practitioner does not currently appear in the CMS individual Order & Referring PECOS file (may practice in pediatrics, commercial-only networks, or hospital-employed settings).

Official CMS NPPES Credential & Practice Profile

10-Digit NPI Number	`1245967405` (NPI-1 Individual Practitioner)
Provider / Legal Name	BRENT JACKSON
Plain-English Specialty	Licensed & Credentialed Physician Assistants & Advanced Practice Nursing Providers — Nurse Practitioner, Acute Care NUCC Code: `363LA2100X` (Nurse Practitioner, Acute Care)
Certifying / Licensing Body	State Medical / Healthcare Licensing Board & National Specialty Board
Practice Location Address	2377 COUNTY ROAD 1201, TUTTLE, OK, 73089-1067
Practice Telephone / Fax	Tel: (405) 412-3213
Administrative Mailing Address	2377 COUNTY ROAD 1201, TUTTLE, OK, 73089-1067
Enumeration & Last Sync	Enumerated: 2022-08-06 \| CMS Record Updated: 2022-09-04

Clinic Location, Accessibility & Directions

📍 Practice Location & Patient Access

2377 COUNTY ROAD 1201, TUTTLE, OK, 73089-1067

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Plain-English Taxonomy & CMS Crosswalk (363LA2100X)

What Does Taxonomy Code 363LA2100X Mean?

In the HIPAA National Uniform Claim Committee (NUCC) classification, code 363LA2100X translates to:
"Licensed & Credentialed Physician Assistants & Advanced Practice Nursing Providers — Nurse Practitioner, Acute Care"

CMS-1500 Medicare Specialty Crosswalk: CMS Code 50 (Nurse Practitioner)
Certifying / Accrediting Authority: State Medical / Healthcare Licensing Board & National Specialty Board
Clinical Scope: Consult a verified Nurse Practitioner, Acute Care for specialized diagnostic evaluation, treatment planning, and continuity of care.

Specialty Clinical Procedures & Therapeutic Classes

Standard Scope of Care (BRENT JACKSON)

Typical CPT / Diagnostic Procedures:

Comprehensive Outpatient & Inpatient Clinical Evaluation (CPT 99202–99215)
Diagnostic Workup, Laboratory Ordering & Evidence-Based Care Coordination
Preventive Screening, Patient Counseling & Multidisciplinary Referral

Common Therapeutic Classes:

Evidence-Based Specialty Pharmacotherapy & Preventive Regimens (CMS Part D Standard)

All Registered NUCC Taxonomies & State Licenses

Taxonomy Code & Plain-English Description	State License & Primary Status
`163W00000X` — Registered Nurse Plain English: Licensed & Credentialed Registered Nurse	State: OK \| License: `96391` \| Primary: Secondary
`363LA2100X` — Nurse Practitioner, Acute Care Plain English: Licensed & Credentialed Physician Assistants & Advanced Practice Nursing Providers — Nurse Practitioner, Acute Care	State: OK \| License: `210172` \| Primary: Yes (Primary)

Medical Billing, RCM & Hospital Credentialing Teams:

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BRENT JACKSON (NPI #1245967405)