Healthcare Provider Details

I. General information

NPI: 1740277532
Provider Name (Legal Business Name): LANELLE JACKSON APN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/05/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 W 7TH ST
LITTLE ROCK AR
72205-5446
US

IV. Provider business mailing address

115 HOLIDAY RD
SOLGOHACHIA AR
72156-8802
US

V. Phone/Fax

Practice location:
  • Phone: 501-257-6844
  • Fax: 501-257-5437
Mailing address:
  • Phone: 501-257-6844
  • Fax: 501-257-5437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAO1239ANP
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: