Healthcare Provider Details

I. General information

NPI: 1609517531
Provider Name (Legal Business Name): JACKSON LOWERY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 07/03/2025
Certification Date: 06/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

665 US HWY 425 S
MONTICELLO AR
71655
US

IV. Provider business mailing address

201 INDEPENDENCE DRIVE
COLUMBUS AFB MS
39710
US

V. Phone/Fax

Practice location:
  • Phone: 870-412-1388
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4607
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4607
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: