Healthcare Provider Details

I. General information

NPI: 1780660159
Provider Name (Legal Business Name): STRACY JACKSON CNA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 S 3RD ST
MC GEHEE AR
71654-2563
US

IV. Provider business mailing address

110 S ADAMS AVE
MC GEHEE AR
71654-2105
US

V. Phone/Fax

Practice location:
  • Phone: 870-222-3805
  • Fax: 870-222-3984
Mailing address:
  • Phone: 870-222-3587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number050024070304E
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: