Healthcare Provider Details

I. General information

NPI: 1093815268
Provider Name (Legal Business Name): AUDRA M JACKSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 08/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3808 SOUTH GARY
FORT SMITH AR
72903-5450
US

IV. Provider business mailing address

PO BOX 402319
ATLANTA GA
30384-2319
US

V. Phone/Fax

Practice location:
  • Phone: 479-709-7120
  • Fax: 479-709-7123
Mailing address:
  • Phone: 479-709-7399
  • Fax: 479-709-7053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE6098
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: