Healthcare Provider Details

I. General information

NPI: 1720003247
Provider Name (Legal Business Name): CHARLES ANDREW JACKSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 03/18/2021
Certification Date: 02/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2263 HWY 65 NORTH
MARSHALL AR
72650
US

IV. Provider business mailing address

2263 HWY 65 NORTH
MARSHALL AR
72650
US

V. Phone/Fax

Practice location:
  • Phone: 870-448-5733
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE-0979
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: