Provider Demographics
NPI:1497828826
Name:JACKSON, LISA LANETTE (APN)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:LANETTE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:APN
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:LANETTE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1117 CHESTNUT
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:71845-1117
Mailing Address - Country:US
Mailing Address - Phone:870-921-5781
Mailing Address - Fax:870-798-4100
Practice Address - Street 1:1117 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:AR
Practice Address - Zip Code:71845
Practice Address - Country:US
Practice Address - Phone:870-921-5781
Practice Address - Fax:870-798-4100
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA02932 ANP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR202614758Medicaid