Provider Demographics
NPI:1326342452
Name:JACKSON ALLERGY & ASTHMA CLINIC P.A.
Entity Type:Organization
Organization Name:JACKSON ALLERGY & ASTHMA CLINIC P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-623-1311
Mailing Address - Street 1:151 HARMONY PARK CIRCLE
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71913-5417
Mailing Address - Country:US
Mailing Address - Phone:501-623-1311
Mailing Address - Fax:501-321-1214
Practice Address - Street 1:151 HARMONY PARK CIRCLE
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913-5417
Practice Address - Country:US
Practice Address - Phone:501-623-1311
Practice Address - Fax:501-321-1214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-04
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC8504174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR187025002Medicaid
AR5J211OtherBCBS
AR5J211OtherBCBS