Healthcare Provider Details

I. General information

NPI: 1316583461
Provider Name (Legal Business Name): ELI NOAH JACKSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2019
Last Update Date: 11/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

942 HIGHWAY 65 N
MARSHALL AR
72650-7772
US

IV. Provider business mailing address

101 W MAIN ST
HARDY AR
72542-9566
US

V. Phone/Fax

Practice location:
  • Phone: 888-518-1418
  • Fax: 870-895-2164
Mailing address:
  • Phone:
  • Fax: 870-856-2133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPT2019-050
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: