Provider Demographics
NPI:1558780478
Name:JACKSON, TERESA (CLS, ASCP)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CLS, ASCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4010 S MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-7000
Mailing Address - Country:US
Mailing Address - Phone:870-541-6012
Mailing Address - Fax:870-541-8696
Practice Address - Street 1:4010 S MULBERRY ST
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-7000
Practice Address - Country:US
Practice Address - Phone:870-541-6012
Practice Address - Fax:870-541-8696
Is Sole Proprietor?:No
Enumeration Date:2014-04-08
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QM0706XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyMedical Technologist