Healthcare Provider Details

I. General information

NPI: 1558545897
Provider Name (Legal Business Name): CHRISTOPHER JACKSON LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2007
Last Update Date: 09/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 HIGHWAY 9
OXFORD AR
72565-0096
US

IV. Provider business mailing address

PO BOX 1589
BENTON AR
72018-1589
US

V. Phone/Fax

Practice location:
  • Phone: 501-315-3344
  • Fax:
Mailing address:
  • Phone: 501-315-3344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberP1109067
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: