Healthcare Provider Details

I. General information

NPI: 1841897576
Provider Name (Legal Business Name): LASHAUNDA JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2020
Last Update Date: 12/21/2025
Certification Date: 10/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1127 SECOND ST
LAKE VILLAGE AR
71653-1541
US

IV. Provider business mailing address

790 ROBERTS DR
MONTICELLO AR
71655-5723
US

V. Phone/Fax

Practice location:
  • Phone: 870-265-3808
  • Fax: 870-265-2733
Mailing address:
  • Phone: 870-367-2461
  • Fax: 870-460-6133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: