Healthcare Provider Details

I. General information

NPI: 1053372946
Provider Name (Legal Business Name): MARTHA A JACKSON DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2006
Last Update Date: 07/14/2020
Certification Date: 07/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 CRESTWOOD RD SUITE 101
NORTH LITTLE ROCK AR
72116-7615
US

IV. Provider business mailing address

2501 CRESTWOOD RD SUITE 101
NORTH LITTLE ROCK AR
72116-7615
US

V. Phone/Fax

Practice location:
  • Phone: 501-771-4785
  • Fax: 501-771-4787
Mailing address:
  • Phone: 501-771-4785
  • Fax: 501-771-4787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number87
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: