Provider Demographics
NPI:1578834693
Name:JACKSON, WHITNEY E (MCD, CF-SLP)
Entity Type:Individual
Prefix:
First Name:WHITNEY
Middle Name:E
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MCD, CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4902 W HWY 158
Mailing Address - Street 2:
Mailing Address - City:MANILA
Mailing Address - State:AR
Mailing Address - Zip Code:72442
Mailing Address - Country:US
Mailing Address - Phone:870-243-3587
Mailing Address - Fax:
Practice Address - Street 1:4902 W HWY 158
Practice Address - Street 2:
Practice Address - City:MANILA
Practice Address - State:AR
Practice Address - Zip Code:72442
Practice Address - Country:US
Practice Address - Phone:870-243-3587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-20
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP#P8531235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR190743721Medicaid