Healthcare Provider Details

I. General information

NPI: 1669886552
Provider Name (Legal Business Name): SHENIKA JACKSON-KING APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2014
Last Update Date: 03/23/2023
Certification Date: 03/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 S SCHOOL ST
DERMOTT AR
71638-2127
US

IV. Provider business mailing address

106 E SPEEDWAY ST
DERMOTT AR
71638-2317
US

V. Phone/Fax

Practice location:
  • Phone: 870-538-5296
  • Fax: 870-538-3701
Mailing address:
  • Phone: 870-538-5414
  • Fax: 870-538-5412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA004123
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: