=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821287830
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHILLIP COREY JACKSON, MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2007
-----------------------------------------------------
Last Update Date | 06/06/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1417 GLADDEN ST
-----------------------------------------------------
City | HARRISON
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72601-5121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-741-0016
-----------------------------------------------------
Fax | 870-741-4242
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1417 GLADDEN ST
-----------------------------------------------------
City | HARRISON
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72601-5121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-741-0016
-----------------------------------------------------
Fax | 870-741-4242
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. PHILLIP COREY JACKSON
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 870-741-0016
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | E3074
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------