Provider Demographics
NPI:1558621367
Name:JACKS DERMATOLOGY P.A.
Entity Type:Organization
Organization Name:JACKS DERMATOLOGY P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-534-7546
Mailing Address - Street 1:1710 W 42ND AVE
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-7008
Mailing Address - Country:US
Mailing Address - Phone:870-534-7546
Mailing Address - Fax:
Practice Address - Street 1:1710 W 42ND AVE
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-7008
Practice Address - Country:US
Practice Address - Phone:870-534-7546
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-26
Last Update Date:2012-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE7442207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty