MEDICARE: KIM NGAN THI JACKSON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RA0201X	Allergy & Immunology (Internal Medicine) Physician	E13055	AR

General Provider Information

NPI Number	:	1902292329
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIM NGAN THI JACKSON MD

Provider Business Mailing Address
First Line	:	18 CORPORATE HILL DR STE 110
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72205-4565
Country	:	US
Telephone Number	:	501-978-7113
Fax Number	:

Provider Business Practice Location Address
First Line	:	18 CORPORATE HILL DR STE 110
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72205-4565
Country	:	US
Telephone Number	:	501-224-1156
Fax Number	:	501-223-2625

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/13/2015
Last Update Date	:	07/07/2021

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