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General NPI Number Information
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NPI Number | 1083882633
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Entity Type | Organization
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Legal Business Name | DAVID C JACKS MD PA
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Dates
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Enumeration Date | 02/18/2008
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Last Update Date | 11/15/2013
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Provider Practice Location Address
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Address Line | 4303 S MULBERRY ST
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City | PINE BLUFF
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State | AR
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Zip | 71603-7017
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Country | US
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Telephone | 870-535-4221
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Fax | 870-535-4228
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Provider Business Mailing Address
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Address Line | 4303 S MULBERRY ST
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City | PINE BLUFF
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State | AR
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Zip | 71603-7017
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Country | US
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Telephone | 870-535-4221
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Fax | 870-535-4228
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Authorized Official
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Title or Position | BILLING MANAGER/ NURSE
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Name | MRS. JUDY FRIZIELLE
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Credential | LPN
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Telephone | 870-535-4221
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | C5066
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License Number State | AR
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