Provider Demographics
NPI:1093105918
Name:JACKSON, AMELIA DEE (NP-C)
Entity Type:Individual
Prefix:
First Name:AMELIA
Middle Name:DEE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1101 JACKSON ST SW
Mailing Address - Street 2:
Mailing Address - City:GRAVETTE
Mailing Address - State:AR
Mailing Address - Zip Code:72736-9121
Mailing Address - Country:US
Mailing Address - Phone:479-787-5221
Mailing Address - Fax:479-787-9692
Practice Address - Street 1:1101 JACKSON ST SW
Practice Address - Street 2:
Practice Address - City:GRAVETTE
Practice Address - State:AR
Practice Address - Zip Code:72736-9121
Practice Address - Country:US
Practice Address - Phone:479-787-5221
Practice Address - Fax:479-787-9692
Is Sole Proprietor?:No
Enumeration Date:2015-01-30
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA004287363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner