Healthcare Provider Details

I. General information

NPI: 1447724604
Provider Name (Legal Business Name): LAURA JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2019
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6910 HIGHWAY 5 N
BRYANT AR
72022-7901
US

IV. Provider business mailing address

6910 HIGHWAY 5 N
BRYANT AR
72022-7901
US

V. Phone/Fax

Practice location:
  • Phone: 501-585-7580
  • Fax: 501-307-2135
Mailing address:
  • Phone: 501-585-7580
  • Fax: 501-307-2135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-22-60124
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: