Healthcare Provider Details

I. General information

NPI: 1770487894
Provider Name (Legal Business Name): ANDREA NICOLE JACKSON PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2026
Last Update Date: 10/03/2026
Certification Date: 10/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4810 W COMMERCIAL DR
NORTH LITTLE ROCK AR
72116-7083
US

IV. Provider business mailing address

53 FALCON DR
SHERWOOD AR
72120-1685
US

V. Phone/Fax

Practice location:
  • Phone: 501-255-9147
  • Fax:
Mailing address:
  • Phone: 501-542-2403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number234936
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: