Provider Demographics
NPI:1124219605
Name:JACKSON, JOANNE
Entity Type:Individual
Prefix:
First Name:JOANNE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 S CHANEY AVE
Mailing Address - Street 2:
Mailing Address - City:BRINKLEY
Mailing Address - State:AR
Mailing Address - Zip Code:72021
Mailing Address - Country:US
Mailing Address - Phone:501-626-3777
Mailing Address - Fax:870-972-4911
Practice Address - Street 1:412 S CHANEY AVE
Practice Address - Street 2:
Practice Address - City:BRINKLEY
Practice Address - State:AR
Practice Address - Zip Code:72021
Practice Address - Country:US
Practice Address - Phone:501-626-3777
Practice Address - Fax:870-972-4911
Is Sole Proprietor?:No
Enumeration Date:2007-08-08
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3747P1801X, 3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant