Provider Demographics
NPI:1497824304
Name:JACKSON, GEORGE WOODY (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:WOODY
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 HIGHWAY 62 412
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:AR
Mailing Address - Zip Code:72542-9497
Mailing Address - Country:US
Mailing Address - Phone:870-856-6000
Mailing Address - Fax:870-856-6001
Practice Address - Street 1:1440 HIGHWAY 62 412
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:AR
Practice Address - Zip Code:72542-9497
Practice Address - Country:US
Practice Address - Phone:870-856-6000
Practice Address - Fax:870-856-6001
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARN7190207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR112923001Medicaid
ARC73512Medicare UPIN
AR112923001Medicaid