Healthcare Provider Details

I. General information

NPI: 1396996740
Provider Name (Legal Business Name): ARKANSAS CENTRAL PRIMARY CARE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2008
Last Update Date: 02/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 BRADEN ST.
JACKSONVILLE AR
72076-3719
US

IV. Provider business mailing address

PO BOX 309
JACKSONVILLE AR
72078-0309
US

V. Phone/Fax

Practice location:
  • Phone: 501-985-5900
  • Fax: 501-985-6016
Mailing address:
  • Phone: 501-985-5900
  • Fax: 501-985-6016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. GARY DREW JACKSON
Title or Position: CLINIC ADMINISTRATOR
Credential:
Phone: 501-985-5994