Provider Demographics
NPI:1316583461
Name:JACKSON, ELI NOAH (PA-C)
Entity Type:Individual
Prefix:
First Name:ELI
Middle Name:NOAH
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HARDY
Mailing Address - State:AR
Mailing Address - Zip Code:72542-9566
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:870-856-2133
Practice Address - Street 1:942 HIGHWAY 65 N
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:AR
Practice Address - Zip Code:72650-7772
Practice Address - Country:US
Practice Address - Phone:888-518-1418
Practice Address - Fax:870-895-2164
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-25
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT2019-050363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical