Healthcare Provider Details

I. General information

NPI: 1902292329
Provider Name (Legal Business Name): KIM NGAN THI JACKSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2015
Last Update Date: 07/07/2021
Certification Date: 07/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 CORPORATE HILL DR STE 110
LITTLE ROCK AR
72205-4565
US

IV. Provider business mailing address

18 CORPORATE HILL DR STE 110
LITTLE ROCK AR
72205-4565
US

V. Phone/Fax

Practice location:
  • Phone: 501-224-1156
  • Fax: 501-223-2625
Mailing address:
  • Phone: 501-978-7113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License NumberE13055
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: