Provider Demographics
NPI:1659477164
Name:JACKSON, NEDRA CLEM (MD)
Entity Type:Individual
Prefix:DR
First Name:NEDRA
Middle Name:CLEM
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301-2001
Mailing Address - Country:US
Mailing Address - Phone:870-735-3842
Mailing Address - Fax:870-394-4872
Practice Address - Street 1:900 N 7TH ST
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-2001
Practice Address - Country:US
Practice Address - Phone:870-735-3842
Practice Address - Fax:870-394-4872
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS21180207Q00000X
ARE-11062207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
302I112036OtherCMS CAHABA
MS07989840Medicaid