Provider Demographics
NPI:1467631556
Name:JACKSON, BRENDA SUE (MHPP)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:SUE
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 1:2400 S. 48TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762
Mailing Address - Country:US
Mailing Address - Phone:479-750-2020
Mailing Address - Fax:479-750-8967
Practice Address - Street 1:2508 S.E. 20TH
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712
Practice Address - Country:US
Practice Address - Phone:479-750-2020
Practice Address - Fax:479-872-2441
Is Sole Proprietor?:No
Enumeration Date:2007-10-25
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
AR171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator