Provider Demographics
NPI:1629745088
Name:JACKSON, BROOKLYN ELIZABETH (FNP)
Entity Type:Individual
Prefix:
First Name:BROOKLYN
Middle Name:ELIZABETH
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:549 REFLECTIONS DR
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:AR
Mailing Address - Zip Code:72650-8981
Mailing Address - Country:US
Mailing Address - Phone:870-490-0633
Mailing Address - Fax:
Practice Address - Street 1:549 REFLECTIONS DR
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:AR
Practice Address - Zip Code:72650-8981
Practice Address - Country:US
Practice Address - Phone:870-490-0633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-24
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR217354363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily