Healthcare Provider Details

I. General information

NPI: 1124219605
Provider Name (Legal Business Name): JOANNE JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2007
Last Update Date: 01/06/2020
Certification Date: 01/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 S CHANEY AVE
BRINKLEY AR
72021
US

IV. Provider business mailing address

412 S CHANEY AVE
BRINKLEY AR
72021
US

V. Phone/Fax

Practice location:
  • Phone: 501-626-3777
  • Fax: 870-972-4911
Mailing address:
  • Phone: 501-626-3777
  • Fax: 870-972-4911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: