MEDICARE: ALEXIS JACKSON CD-L, CD-PIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	374J00000X	Doula

General Provider Information

NPI Number	:	1952166639
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALEXIS JACKSON CD-L, CD-PIC

Provider Business Mailing Address
First Line	:	9006 PENROSE LN
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72205-4654
Country	:	US
Telephone Number	:	501-240-5140
Fax Number	:

Provider Business Practice Location Address
First Line	:	9006 PENROSE LN
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72205-4654
Country	:	US
Telephone Number	:	501-240-5140
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/20/2024
Last Update Date	:	03/09/2024

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