Provider Demographics
NPI:1295865905
Name:JACKSON, KIMBERLY ROSE (MHPP)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:ROSE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MHPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 DONS WAY
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71913
Mailing Address - Country:US
Mailing Address - Phone:501-620-5130
Mailing Address - Fax:501-620-5203
Practice Address - Street 1:125 DONS WAY
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913
Practice Address - Country:US
Practice Address - Phone:501-620-5130
Practice Address - Fax:501-620-5203
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator