Provider Demographics
NPI:1447742408
Name:JACKSON, PAMELA DENISE
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:DENISE
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 1:1600 ALDERSGATE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-6676
Mailing Address - Country:US
Mailing Address - Phone:501-661-0720
Mailing Address - Fax:501-325-7938
Practice Address - Street 1:613 N FISHER ST
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-2152
Practice Address - Country:US
Practice Address - Phone:870-932-6922
Practice Address - Fax:870-910-4999
Is Sole Proprietor?:No
Enumeration Date:2018-06-05
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator