Provider Demographics
NPI:1174506448
Name:JACKSON, EDWARD LESLIE (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:LESLIE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1523
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72702-1523
Mailing Address - Country:US
Mailing Address - Phone:479-521-8200
Mailing Address - Fax:479-582-7310
Practice Address - Street 1:3344 N FUTRALL DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4057
Practice Address - Country:US
Practice Address - Phone:479-521-8200
Practice Address - Fax:479-582-7310
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-4775207RC0200X, 207RP1001X, 207RP1001X
AL21925207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5N545OtherAR BCBS
ARP00327943OtherRR MCR
AR160768001Medicaid
OK200088310AMedicaid
AR5N545Medicare ID - Type Unspecified
OK200088310AMedicaid
G83599Medicare UPIN