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General NPI Number Information
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NPI Number | 1548227481
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Entity Type | Individual
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Provider Name | PHILLIP COREY JACKSON MD PA
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Gender | Male
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Dates
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Enumeration Date | 04/26/2006
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Last Update Date | 08/11/2014
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Provider Practice Location Address
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Address Line | 1417 GLADDEN ST
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City | HARRISON
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State | AR
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Zip | 72601-5121
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Country | US
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Telephone | 870-741-0016
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Fax | 870-741-4242
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Provider Business Mailing Address
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Address Line | 1417 GLADDEN ST
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City | HARRISON
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State | AR
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Zip | 72601-5121
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Country | US
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Telephone | 870-741-0016
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Fax | 870-741-4242
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | E3074
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License Number State | AR
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