Healthcare Provider Details

I. General information

NPI: 1962677906
Provider Name (Legal Business Name): CRESTWOOD FOOT CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2008
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
72116-6864
US

IV. Provider business mailing address

2501 CRESTWOOD RD SUITE 101
NORTH LITTLE ROCK AR
72116-6864
US

V. Phone/Fax

Practice location:
  • Phone: 501-771-4785
  • Fax: 501-771-4785
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: DR. MARTHA A. JACKSON
Title or Position: OWNER
Credential: DPM
Phone: 501-771-4785