=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619403615
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS M JACKSON DMD, MSD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2017
-----------------------------------------------------
Last Update Date | 07/27/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2737 PAULA DR
-----------------------------------------------------
City | JONESBORO
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72404-8017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-932-0015
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 327
-----------------------------------------------------
City | WALNUT RIDGE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72476-0327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-886-7992
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 39
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------