Provider Demographics
NPI:1114385374
Name:JACKSON, TIFFANY MICHELLE (APRN, AGNP-C)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:MICHELLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:APRN, AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 E APPLEBY RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-3901
Mailing Address - Country:US
Mailing Address - Phone:479-463-4444
Mailing Address - Fax:479-463-4499
Practice Address - Street 1:12 E APPLEBY RD
Practice Address - Street 2:SUITE 101
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-3901
Practice Address - Country:US
Practice Address - Phone:479-463-4444
Practice Address - Fax:479-463-4499
Is Sole Proprietor?:No
Enumeration Date:2016-02-03
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA004646363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care