Healthcare Provider Details

I. General information

NPI: 1043365620
Provider Name (Legal Business Name): JANISSA D JACKSON PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 ROGERS AVE STE 201
FORT SMITH AR
72903-3763
US

IV. Provider business mailing address

5401 ROGERS AVE STE 201
FORT SMITH AR
72903-3763
US

V. Phone/Fax

Practice location:
  • Phone: 479-242-4560
  • Fax: 479-242-4561
Mailing address:
  • Phone: 479-242-4560
  • Fax: 479-242-4561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number07-01P
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number07-01P
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: